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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 04/17/2023
Date Signed: 04/17/2023 04:32:44 PM


Document Has Been Signed on 04/17/2023 04:32 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:
04/17/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Crystal & Alex PakTIME COMPLETED:
03:31 PM
NARRATIVE
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On 04/17/23 at 3:00 pm, an office meeting was conducted with Administrator Crystal Pak, Licensee Alex Pak, and potential owner Jung Suk So by telephone through a conference call. In attendance are Regional Managers (RM) Benita Yates and Araceli Ramirez, Licensing Program Manager (LPM) Janae Hammond, and Licensing Program Analyst (LPA) Ernand Dabuet. The purpose of this meeting was to discuss the procedures for Change of Ownership.

Administrator Pak stated only the processing of documentation has been agreed upon and no financial transactions have taken place. The new owner has taken a tour of the facility and has agreed to retain the residents and will potentially bring in new staff by the new owners. Pak stated the facility is not responsible for the resident’s finances and that a current general liability insurance is maintained for Hayworth Terrace.

During the office meeting (RM) Yates conducted a brief overview of the terms and conditions for the Change of Ownership for Hayworth Properties, LLC. Discussions of limitations and conditions for a Change of Ownership, in which the following items were emphasized.
  • Submit notification “Letter of Intent"
  • Draft Letter to Residents, Conservators, Family Representatives, and Ombudsman
  • Maintain Control of Property
  • Submit New LIC 200 Application to Central Application Bureau

A timeframe was agreed upon during this meeting that the current licensee and new owner will have the notification of the Letter of Intent submitted to Community Care Licensing on or before 05/17/23.

The meeting concluded at 3:31 pm. An exit interview conducted, and the report provided by email to Crystal Pak.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
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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