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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 11/13/2023
Date Signed: 11/15/2023 08:15:20 AM


Document Has Been Signed on 11/15/2023 08:15 AM - 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 AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 60DATE:
11/13/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Crystal Pak TIME COMPLETED:
04:00 PM
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On 11/13/23 at 3:30pm, a virtual meeting was held by the El Segundo Adult & Senior Care Regional Office. Regional Manager, Benita Yates, and Licensing Program Manager, Janae Hammond met with the Administrator Crystal Pak to discuss the Decision and Order # 6223131301 that was rendered against the facility. The Licensee Alex Pak was unavailable to join the meeting and authorized Crystal Pak to participate on his behalf during today’s meeting.

Regional Manager, Benita Yates discussed the Decision and Order with the above mentioned parties. The Decision and Order which stated, The license of Hayworth Terrace to operate a residential care facility for the elderly is revoked effective as of 01/08/2024; Crystal Pak is prohibited from employment, operating or having contact with residents in facilities licensed by the State of California; the Administrator certificate for Crystal Pak is revoked effective 11/13/2023.

Ms. Pak stated that currently the facility census is 60 residents. Ms. Pak indicated that Bella Lee is the current acting administrator of the facility effective 11/14/23, pending the hiring of a new Administrator.

SUPERVISOR'S NAME: Benita YatesTELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023
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: 11/13/2023
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The Licensee will complete the below items and submit to Community Care Licensing:

· Submit to the department the plan of the facility closure in adherence to Title 22, Division 6 Chapter 3.2 Residential Care Facilities for the Elderly Article 06. Other Provisions, 1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties. Due by: 11/27/2023

· Update and submit to the department the residents Pre-Placement Appraisal/ Needs & Service Plan and relocation packet. Due by:12/1/2023

· Licensee will ensure that the decision and order will be posted at the facility per Title 22, Division 6, Chapter 3.2 Residential Care Facilities for the Elderly, Article 03. Regulations, section 1569.38 Posting of licensing reports; disclosure to new residents.

· Submit updated Personnel Report LIC 500 and updated Resident Roster. Due by: 11/27/2023

A Change of Ownership Application was submitted to the department and is pending at this time.

Hayworth Terrace is prohibited from accepting residents at this time.

The department will conduct case management visits at the facility to follow up on the closure.

A copy of this report along with a copy of the "decision and order" and aforementioned regulations regarding the facility closure and posting of licensing reports were provided via email.

SUPERVISOR'S NAME: Benita YatesTELEPHONE: (323) 981-3962
LICENSING EVALUATOR NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
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