197607682-11-6-2023-11-AS-UCOL-D4EMFG-20240417093414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:34:33 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/30/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231030163649

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	CRYSTAL PAK		FACILITY TYPE:	740
ADDRESS:	325 N HAYWORTH AVE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 50	DATE:	11/06/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Crystal Pak, Administrator		TIME COMPLETED:	04:31 PM

ALLEGATION(S):

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Staff do not provide snacks to residents.
Facility has pests.

INVESTIGATION FINDINGS:

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On 11/06/23, Licensing Program Analyst (LPA) Mario Leon and Long-Term Care Ombudsman (LTCO) Jaime Cortes conducted a joint 10-day complaint investigation at the facility listed above. LPA and LTCO met with Crystal Pak, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 11/06/23, the investigation consisted of the following:

During today's visit LPA toured the facility, mainly focused on the food storage areas and kitchen. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Admission agreement, Pest Control Invoices, Weekly Menus for past two weeks and requested food delivery receipts. LPA interviewed nine (9) of fifty (50) residents and interviewed five (5) out of twenty-five (25) staff.

Report continued on LIC9099-C

Substantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231030163649

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 11/06/2023

NARRATIVE

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Regarding the allegation: "Staff do not provide snacks to residents" It has been alleged that snacks are kept in the medication room. LPA and LTCO toured the medication room and observed no snacks present. LPA and LTCO toured the kitchen and observed no snacks present. LPA and LTCO toured the facility and interviewed 9 out of 50 residents. Three (3) out of nine (9) residents agreed that they get no snacks and two (2) out of nine (9) residents are not happy with the peanut butter and jelly sandwich (PB&J) choice.
Three (3) out of five (5) staff confirm the snack choice is PB&J and that forty (40) sandwiches are made before snack times. LPA and LTCO both observed that two (2) out of 2 menus do not display "snack" on the menu.
Based on LPA's observation, interviews and record reviews conducted, there is enough evidence to support the allegation "Staff do not provide snacks to residents" The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Title 22, Division 6, Chapter 8 has been cited, see LIC9099D.

Regarding the allegaton: "Facility has pests" It has been alleged that pests run rampant in the kitchen area. LPA and LTCO toured the kitchen and dining room area and from the first (1st) floor to the rooftop. LPA reviewed exterminator records, dating back to February, 2023. Throughout the tour of the facility, LPA and LTCO observed small cockroaches present throughout the facility. The cockroaches were seen dead and alive in the dining room, dead in the kitchen storage room, alive in the non-perishable food storage room, dead and alive in the recreation room, and dead in the lounge room. LPA and LTCO observed flour beetles and what appeared to be cockroach eggs and cockroach droppings in the non-perishable food storage room. LPA and LTCO observed rodent droppings in the recreation room, nearby the glass door.
LPA interviewed 9 out of 50 residents and eight (8) out of nine (9) corroborate the allegation, all which mention "bedbug". Although the facility has taken measures against pests and rodents, the pests and presence of rodents are still present.
Based on LPA's observation, interviews and record reviews conducted, there is enough evidence to support the allegation "Facility has pests" The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. Title 22, Division 6, Chapter 8 has been cited, see LIC9099D.

An exit interview was held with Crystal Pak, Administrator and a copy of this report and appeal rights have been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231030163649

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/14/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agrees to maintain a contract with a licensed exterminator for bed bugs, roaches, and pests, and to provide a written plan to CCLD outlining an updated, revised, approach to eradicate the facility of pests.
	8 9 10 11 12 13 14	Based on LPA's observation and interviews conducted, the licensee did not comply with the section cited above. LPA observed dead and live cockroaches throughout the facility. LPA's interviews support the allegation. Civil penalties are now being assessed.	8 9 10 11 12 13 14	POC due date of 11/14/23 and shall be submitted to LPA at Mario.Leon@dss.ca.gov
Type B 11/14/2023 Section Cited CCR 87555(b)(3)	1 2 3 4 5 6 7	87555(b)(3) General Food Service Requirements.The following food service requirements shall apply: Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician.	1 2 3 4 5 6 7	LPA and Administrator have agreed to update the menu plan to include the word "snack". LPA and Administrator have agreed to have a list of snack choices below the weekly menu.
	8 9 10 11 12 13 14	Based on LPA's observation and interviews conducted, the licensee did not comply with the section cited above. LPA interviewed nine residents, 5 out of 9 residents supported the allegation.	8 9 10 11 12 13 14	Administrator will send updated menu plan and food snack invoice for the following week on or prior to POC due date. Mario.Leon@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC9099 (FAS) - (06/04)

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