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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 03/03/2023
Date Signed: 03/03/2023 12:07:41 PM


Document Has Been Signed on 03/03/2023 12:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
197607682
ADMINISTRATOR:CRYSTAL PAKFACILITY TYPE:
740
ADDRESS:325 N. HAYWORTH AVENUETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: DATE:
03/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:13 AM
MET WITH:Crystal PakTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Perry Scott conducted a Case Management visit to serve an "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for Staff #1 to Administrator, Crystal Pak.

An investigation by the California Department of Social Services was conducted; and it was determined that Staff #1 violated resident #1's Personal Rights. Government Code Section 11522 was issued informing of Staff #1 an "excluded" person may petition for reinstatement to the Department no less than one (1) year after the effective date of the Exclusion Order.

LPA Scott delivered (in person) to the facility the "Immediate Exclusion" letter for Staff #1 to the Administrator,
Crystal Pak. It should be noted that copies of the letters will be sent (via "certified" U.S. Mail) to both parties.

An exit interview was conducted and copy of this report provided to Administrator.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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