197607682-4-14-2023-11-AS-EMAZ-CRJTQ6-20230505145523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 01/12/2023
Date Signed: 04/14/2023 11:59:19 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/03/2023 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230103092320

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	CRYSTAL PAK		FACILITY TYPE:	740
ADDRESS:	325 N. HAYWORTH AVENUE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 57	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Julieta Arriola		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Resident pushed another resident in care.

INVESTIGATION FINDINGS:

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This report serves as an amendment to the complaint report created on 1/12/2023. This report supersedes the complaint investigation findings reflected on the complaint report created on 1/12/2023.
Licensing Program Analyst (LPA) Martessa Brown conducted an unannounced initial 10-day complaint visit to the above facility to investigate the above allegation. LPA was met by Julieta Arriola, Medical Technician and later was met by Administrator Crystal Pak and the purpose of today’s visit was explained.

Investigation consisted of the following: On 1/12/2023, LPA conducted interviews with staff members (S1-S4) and the administrator Crystal Pak, residents (R1-R3), LPA requested the following documents: Incident Report pertaining to the above allegation, obtained Resident (R1-R2) files: Physicians Reports, Needs & Services, Emergency Contacts, Staff & Resident Roster.
The investigation revealed the following:

Regarding the allegation: Resident pushed another resident in care.
LIC 9099-C is on the next page

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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-20230103092320

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 01/12/2023

NARRATIVE

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It was alleged that resident R1 was pushed by R2 on 12/27/22 and fell on the floor and was taken to the hospital. On 1/12/2023, LPA conducted interviews with 4 staff members (S1-S4) and the administrator Crystal Pak regarding the above allegation. Staff (S1-S2) stated R1 was pushed by R2 while waiting for the elevator and both residents were on the floor on 12/27/22. Interviews conducted on 1/12/2023, with the administrator and S3-S4 stated they were aware of the incident that took place on 12/27/22. Staff and the administrator stated on 12/27/22 they were told R1 was waiting for the elevator and R2 was exiting off the elevator and pushed R1. Administrator stated R2 pushed R1 intentional and filed a police report. Both residents were taken to the hospital for observations. On 1/12/23, LPA needed a translator to interview R1, resident stated had fell and hurt their back but as a result of being pushed by R2. Interview conducted with R2, stated was on the elevator and R1 was trying to get on while door was closing and pushed out their hands. LPA reviewed the following documents, Incident Reported, most recent Physicians reported dated in 2019 and R2 had no history of being aggressive. LPA reviewed R2’s needs and Services dated 1/5/22, revealed that R2 is having difficulties with resident/staff and behavior is getting worse, uncooperative and gets upset easily. Based on Interviews and documents gathered during this investigation, LPA found sufficient evidence to support that above mentioned allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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