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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 04/24/2023
Date Signed: 04/27/2023 03:52:37 PM


Document Has Been Signed on 04/27/2023 03:52 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
CCLD Regional Office, 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: 59DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:17 AM
MET WITH:Crystal Pak, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Ana Soto and Ernand Dabuet conducted an unannounced Annual required visit to the above facility. LPA was met by Juan Carlos Russelle, Maintenance Supervisor and later spoke with Crystal Pak, Administrator and the purpose of today’s visit was explained.

There are currently (59) residents in the facility. (31) residents are ambulatory, (28) are non-ambulatory, and (6)Bedridden. The facility is a 2 story beige building located in a residential neighborhood. It consists (72) bedrooms, (77) full bathrooms, shaded court yard, laundry area back of building, 3 TV rooms, 2 lounge areas, dining room, kitchen, storages rooms, and basement.

LPA's and Maintenance Supervisor toured the entire facility inside and out. Documents are posted as mandated by the DPH and CCLD. INFECTIOUS CONTROL PRACTICES - LPA observed a sanitizing station at the facility entry. Sanitizer/soap and paper towels in all the bathrooms and additional sanitation supplies are stored in 2nd Floor Storage. LPA observed some staff wearing masks, Residents private rooms will be converted to isolation rooms (if needed) trash cans with lids, cart for PPE’s, mitigation plan posted and/or in folder, Fit testing completed for staff, infectious Control Plan posted and/or in folder, Emergency infectious Plan posted and/or in folder, and required postings throughout the facility. Visitor designated area, Emergency contacts updated and posted; PPEs are enough for 30 days. All resident's and staff are vaccinated and boosted.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 04/24/2023
NARRATIVE
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OPERATIONAL REQUIREMENT - Fire clearances are incompliance. PHYSICAL PLANT ENVIRONMENTAL SAFETY - Bedrooms are occupied by residents and contain the mandated furniture. One staff bedroom. Bathrooms have nonskid mats, bars, and are clean and operational. (8) fire extinguishers are fully charged. First Aid kit complete with manual. The water temperature is at 110-114 degrees Fahrenheit. Linens and personal hygiene supplies are adequate. A comfortable temperature is maintained in the facility. Smoke detectors and carbon monoxide detectors are complying and operational. hazardous toxins and/or items are inaccessible to residents. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Due to time constraints. The dining room wall has water damage w/mold, 2 kitchen stoves 1- stove have 3 burners not working and 2nd stove has 1 burner not working properly, staff use matches to light pilots for both stoves. Faucet in 1 kitchen sick not working, The call system in facility not operable. Telephone system operational. Exit, walkways and/or passageways, front yard and back yard are free of debris and/or hazards. The facility is in decent repair. STAFFING AND PERSONNEL RECORD TRAINING - 5 staff files are current with valid CPR cards, no egress system, no volunteers at the facility, Excluded employee was observed working and helping the resident's at the facility. RESIDENTS REC - INCIDENT REPORT- 4 Resident files are current along with medications & 1 file missing record. RESIDENT'S RIGHTS - Internet access along with IPHONE, visitor policy posted, PUB 475 posted. PLANNED ACTIVITIES - shaded area, indoor and outdoor activity area. FOOD SERVICE - Ample supply of perishable and nonperishable food and menu posted. INCIDENTAL M&D – The MARS is updated and complete. Resident’s medications are being given as prescribed by their physician. DISASTER PREPAREDNESS – The facility has an emergency and disaster plan, staff knows were shut off valves are located, flashlights available along with batteries, cell phones, additional emergency provisions, and conducted fire drill in April 2023. RESIDENT'S W/SHN - Some residents within facility require postural support, use oxygen and have sign posted, a neurological condition, facility did not notify CCLD of locked perimeter and did not get approval from Fire Marshall.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 04/24/2023
NARRATIVE
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Technical Advisories (TA) issued.
1. No - infectious Control Plan posted and/or in folder

2. No- Emergency infectious Plan posted and/or in folder,

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

Due to time constraints LPA's could not finish annual inspection, LPA's will return at a later date to complete annual inspection and issue additional citations.



Civil Penalty was assessed for excluded employee working at facility.

An exit interview was conducted with Crystal Pak, Administrator and a hard copy of report was provided and Appeal Rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/27/2023 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87777(a)

87777(a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59.
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on LPA observed excluded employee working and helping residents at the facility.
POC Due Date: 04/24/2023
Plan of Correction
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Administrator to remove excluded employee immediately from facility. Employee removed themselves from facility, as soon as they saw LPA.
Type A
Section Cited
CCR
87405(d)(1)(2)

87405(d) (1)(2)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. Knowledge of the requirements for providing care and supervision appropriate to the residents. Knowledge of and ability to conform to the applicable laws, rules and regulations.
Deficient Practice Statement
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This was not as evidence by: based on LPA observed excluded employee working and helping residents at the facility.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator to create a plan on how tho enforce excluded employees from not working and returning to facility. Send to LPA on or before POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8


Document Has Been Signed on 04/27/2023 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on no infectious control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator to provide copy of plan.
Type B
Section Cited
CCR
87303(i)(1)(A)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on signal system not working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Administrator repair signal system and proivde repair invoice to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 04/27/2023 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)(1)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on R#1 did not have Needs and services/Appraisal which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2023
Plan of Correction
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Administrator to obtain form and included in R#1 file and send copy to LPA on or before due date.
Type B
Section Cited
CCR
87705(k)
Care of Persons with Dementia
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egress devices on exterior doors or perimeter fence gates:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Facilities egress system is not operational, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator to repair and/or purchase new egress system
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 04/27/2023 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(l)(1)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on administrator did not inform CCLD about their outside gate on the north side is locked at all times, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Administrator to take lock off and leave outside gate open and send picture of unlocked outside gate door by POC due date.
Type B
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on need to have fire clearance that outside locked perimeter is approved, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/24/2023
Plan of Correction
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Administrator to verify and get approval with Fire Marshall on locked outside gate perimeter.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 04/27/2023 03:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

Deficient Practice Statement
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. This was not net as evidence by: Based on dining room wall has water damage and mole. The kitchen 2 stoves, 1 stove has 3 burners not working properly and 1 stove has a burner not working properly, staff uses matches to light pilot. Kitchen faucet broken and not working.
POC Due Date: 05/24/2023
Plan of Correction
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Administrator to repair wall, stoves, and faucet and send picture of repairs and invoices of repairs to LPA on or before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8