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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:10:28 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
07/25/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230725170358
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: 53DATE:
10/05/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Crystal PakTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff are inappropriately restraining residents.
Staff are not adequately addressing residents' fall risk.
Staff are not ensuring that facility is free from pests.
Staff are not storing toxic chemicals properly.
INVESTIGATION FINDINGS:
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13
On 08/03/23, Licensing Program Analysts (LPAs), Perry Scott and Wendy Gibbs conducted a joint 10-day complaint investigation at the facility listed above. LPA Scott and Gibbs met with Crystal Pak, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/03/23, the investigation consisted of the following:

During today's visit LPA toured the facility. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Id/Emergency Information, Physicians Report, Dietician/Nutritionist Report, Pest Control Invoices, Admission Agreements, List of all SSI Residents, Billing History of Residents, Activity Calendar, List of incontinent Residents, Activity Director Application/Certificate, and a listing of Staff Trainings.

Report continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
NARRATIVE
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On 08/11/23, Licensing Program Analysts (LPAs), Perry Scott and Wendy Gibbs conducted a subsequent complaint investigation visit at the facility listed above. LPA Scott and Gibbs met with Crystal Pak, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/11/23, the investigation consisted of the following:

During today's visit LPA’s conducted interviews with staff (S1-S7) and residents (R1-R11).

The investigation revealed the following- Allegation: Staff are inappropriately restraining residents.

It is alleged that staff are restraining its residents with scarves, soft ties, and belts. On 8/11/23, LPAs interviewed the Administrator Crystal Pak regarding allegation during the interview the Administrator stated restraints are used and indicated it is included on the Residents Physicians Reports. On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied the allegation that Staff are inappropriately restraining residents. 5 of the 7 staff members stated that restraints are not used or are prohibited.

LPAs interviewed R1-R11 about the allegation that Staff are inappropriately restraining residents. 7 of 11 residents deny the allegation that they are being inappropriately restrained. They state that they are not being restrained by the staff. Four (4) residents could not be interviewed due to cognitive difficulties. LPAs conducted a file review and noted (2 residents R6 & R7) with physician’s order for soft tie-on foot to the bed frame to prevent falling from the bed was observed.

Based on interviews, observations, and records review, there is evidence to support the allegation that Staff are inappropriately restraining residents as the facility is in violation of Title 22 Regulations Postural Supports. The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
NARRATIVE
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Allegation: Staff are not adequately addressing residents' fall risk.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied the allegation that Staff are not adequately addressing residents' fall risk. Of those interviewed, they stated that the residents were not at risk for falls. However, those who have dementia or have minimal limited ambulatory status are accessed by a doctor to determine what they can do to keep the resident safe. LPAs interviewed R1-R11 about the allegation that Staff are not adequately addressing residents' fall risk. 7 of 11 residents state that they are not a fall risk and have not fallen recently. Four (4) residents could not be interviewed due to cognitive difficulties.

LPAs conducted a file review and observed on R6 and R7 physicians report it states both residents are a high fall risk. And to prevent falls residents are to be tied to the bed by residents’ foot. LPA did not observe a documented plan in place on file to properly address residents’ fall risk.

Based on interviews and records reviewed, there is evidence to support the allegation that Staff are not adequately addressing residents' fall risk. The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

Allegation: Staff are not ensuring that facility is free from pests.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 6 of 7 staff denied the allegation that Staff are not ensuring that facility is free from pests. Most of the staff deny that the facility has any pests. S1 states that they have an exterminator who takes care of the pest problems when they arise. LPAs interviewed R1-R11 about the allegation that Staff are not ensuring that facility is free from pests. 6 of 11 residents deny that they have seen any pests in the facility. Four (4) residents could not be interviewed due to cognitive difficulties.

However, LPAs observed that the facility indeed had pests. Roaches were observed in residents’ rooms as well as bed bugs in the bed with a resident. The facility does have a pest control company that comes out monthly, but the problem persists.

Based on interviews, observations, and records reviewed there is sufficient evidence to support the allegation: Staff are not ensuring that facility is free from pests. The preponderance of evidence standard has been met; therefore, the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
NARRATIVE
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Allegation: Staff are not storing toxic chemicals properly.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied that Staff are not storing toxic chemicals properly. And 2 of 7 staff did not know where the chemicals were stored. S1 stated that “maintenance keeps them in a locked closet that has limited access to it”. S3 corroborated and stated, “chemicals were stored in a locked cabinet with limited access and not all staff have access to the cabinet”.

LPAs interviewed R1-R11 about the allegation that Staff are not storing toxic chemicals properly. 7 of 11 denied the allegation and stated that they have not observed any chemicals which were not stored properly. However, upon a tour of the facility, LPAs did observe a cart left unattended with a spray bottle that contained chemicals which could cause a potential risk to residents in care.

Based on interviews and observations, there is sufficient evidence to support the allegation: Staff are not storing toxic chemicals properly. The preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are cited on the attached LIC 9099D.

Deficiencies were cited.

An exit interview was conducted, and a copy of this report was given to Crystal Pak, Administrator.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2023
Section Cited
CCR
87608(a)(5)
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Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes…the facility shall provide assistance and care for the resident in those activities… resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met as evidence by:
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Administrator shall schedule in-service training for staff on Postural Supports and Personal Rights of residents and submit proof of scheduling by 10/06/23. Administrator will provide LPA, by email, staff meeting sign in sheet, regarding review of title 22 regulations for resident's Personal Rights and Postural Supports. POC due date 10/13/23 at perry.scott@dss.ca.gov
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Based on interviews, observation and records reviewed the Licensee failed to ensure postural supports were used appropriately to prevent restraining residents and limiting the use of hands and feet. This poses an immediate Health & Safety risk to residents in care.
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Type B
10/13/2023
Section Cited
CCR
87303(a)
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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:
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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 a revised approach to eradicate facility of pests. POC due date of 10/13/23 and shall be submitted to LPA Perry Scott at perry.scott@dss.ca.gov
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Based on observation, the licensee did not comply with this section. LPA observed roaches, and bed bugs in the facility. This poses a potential health, safety, or personal rights risk to persons in care.
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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) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2023
Section Cited
CCR
87309(a)
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87309(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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The Administrator will ensure that all hazardous chemicals are stored in a locked storage cabinet not accessible to residents in care. In addition, licensee will have in-service training with staff regarding this topic. A copy of staff attendance for training will be submitted to LPA (by email) as proof of correction by POC due date 10/13/23 at perry.scott@dss.ca.gov.
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Based on observation, the licensee did not comply with the section cited above. LPAs observed an unattended cart in the sitting area of the facility with a spray bottle of toxic chemicals. This poses a potential risk to the health and safety of residents.
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Type B
10/13/2023
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties
(d) 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. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Administrator shall read Title 22, Section 87405(d)(1) through (7) “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due by POC date 10/13/23 and shall be submitted to LPA Perry Scott at perry.scott@dss.ca.gov
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Based on LPAs records reviewed, and interviews conducted the administrator failed to ensure that residents fall risk was properly addressed as well as proper use of postural support.
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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) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 11
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
07/25/2023 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230725170358

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:
10/05/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Crystal PakTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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2
3
4
5
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8
9
Staff are threatening residents.
Resident's are not being provided with activities.
Staff are not according resident(s) privacy.
Staff are interfering with residents' rights to file a complaint with the State Ombudsman.
Facility does not have enough staff to meet the needs of residents in care.
Facility rooftop poses a hazard to residents.
INVESTIGATION FINDINGS:
1
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3
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5
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7
8
9
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13
On 08/03/23, Licensing Program Analysts (LPAs), Perry Scott and Wendy Gibbs conducted a joint 10-day complaint investigation at the facility listed above. LPA Scott and Gibbs met with Crystal Pak, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/03/23, the investigation consisted of the following:

During today's visit LPA toured the facility. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Id/Emergency Information, Physicians Report, Dietician/Nutritionist Report, Pest Control Invoices, Admission Agreements, List of all SSI Residents, Billing History of Residents, Activity Calendar, List of Incontinent Residents, Activity Director Application/Certificate, and a listing of Staff Trainings.

Report continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
NARRATIVE
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On 08/11/23, Licensing Program Analysts (LPAs), Perry Scott and Wendy Gibbs conducted a subsequent complaint investigation visit at the facility listed above. LPA Scott and Gibbs met with Crystal Pak, Administrator, and explained the purpose of today’s visit was to investigate the allegations listed above.

On 08/11/23, the investigation consisted of the following:

During today's visit LPA’s conducted interviews with staff (S1-S7) and residents (R1-R11).

The investigation revealed the following- Allegation: Staff are threatening residents.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 6 of 7 staff denied the allegation that Staff are threatening residents. It is alleged that staff were threatening residents and told them to “Watch what you say, they may ask questions, and they’re from the state government”. All staff deny that they are or have been threatening residents in any way. LPAs interviewed R1-R11 about the allegation that Staff are threatening residents. 7 of 11 residents denied the allegation that staff were threatening them; and four (4) residents couldn’t be interviewed due to cognitive difficulties.

Based on interviews, there is insufficient evidence to support the allegation that Staff are threatening residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Residents are not being provided with activities.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied the allegation that Residents are not being provided with activities. Staff stated that the residents are provided activities. In that they have worksheets and games that are tailored to the resident’s capabilities. Additionally, they have sing-alongs, Karaoke, board games, bingo, and walking as exercise. LPAs interviewed R1-R11 about the allegation that Residents are not being provided with activities. 3 of 11 residents denied that Residents are not being provided with activities. They state they are provided activities. Four (4) residents could not be interviewed due to cognitive difficulties. LPAs observed that the residents were participating in sing-alongs and participating in light exercises tailored to their capabilities. Furthermore, there was an activity board that outlined the activities for the month for the residents.

Based on interviews, records reviewed, and observations, there is insufficient evidence to support the allegation that Residents are not being provided with activities. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report continued on LIC9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
NARRATIVE
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Allegation: Staff are not according resident(s) privacy.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied that Staff are not according resident(s) privacy. Most of the staff stated that the residents’ privacy is important. They state that when assisting a resident with dressing or incontinent care, they close the door or if in a private room they use a divider to ensure privacy. LPAs interviewed R1-R11 about the allegation that Staff are not according resident(s) privacy. 6 of 11 residents denied the allegation and stated that they are given privacy or don’t need that type of assistance from the staff. Four (4) residents could not be interviewed due to cognitive difficulties.

Based on interviews, there is insufficient evidence to support the allegation that Staff are not according resident(s) privacy. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff are interfering with residents' rights to file a complaint with the State Ombudsman.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 4 of 7 staff denied the allegation that Staff are interfering with residents' rights to file a complaint with the State Ombudsman. Most of the staff stated that they or other staff has not interfered with the resident’s right to file a complaint with the Ombudsman. LPAs interviewed R1-R11 about the allegation that Staff are interfering with residents' rights to file a complaint with the State Ombudsman. 7 of 11 residents denied the allegation and verified that the staff was not preventing them from filing a complaint with the Ombudsman. Four (4) residents could not be interviewed due to cognitive difficulties.

Based on interviews, there is insufficient evidence to support the allegation that Staff are interfering with residents' rights to file a complaint with the State Ombudsman. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Facility does not have enough staff to meet the needs of residents in care.

On 08/11/23, from 09:40am-04:00pm, LPAs interviewed S1-S7 & R1-R11. 5 of 7 staff denied the allegation that Facility does not have enough staff to meet the needs of residents in care. Most of the staff feel that there is sufficient staffing. S1 states that there are enough staff to meet the needs of the residents. S1 also states that there are 4 caregivers, 1 med-tech, and 1 activities director on each shift.

LPAs observed the personnel report and found that it was sufficient to meet the needs of the residents. The current schedule has 14 Direct Care Providers, 2 Med-Techs, 5 Activity Personnel, and administrative staff on site. LPAs interviewed R1-R11 about the allegation that the Facility does not have enough staff to meet the needs of residents in care. 6 of 11 denied the allegation that there were not enough staff to meet the needs of the residents. They stated that there are enough staff to meet the needs of residents. Four (4) residents could not be interviewed due to cognitive difficulties.

Report continued on LIC9099-C.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 10 of 11
Control Number 11-AS-20230725170358
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: 10/05/2023
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Based on interviews, there is insufficient evidence to support the allegation that the Facility does not have enough staff to meet the needs of residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated

Allegation: Facility rooftop poses a hazard to residents.

On 08/11/23, LPAs toured the roof at the facility with maintenance (S3). LPAs observed that to get to the rooftop from the elevator, you need access. And to get access to the roof you need a key. All other entry points to the roof were locked and gated. Upon reviewing the roof, LPAs observed that the rooftop did not have any obstructions that would pose a hazard to residents if they were to gain access to it.

Based on observations, there is insufficient evidence to support the allegation that the Facility rooftop poses a hazard to residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted, and a copy of this report was given to Crystal Pak, Administrator.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Perry ScottTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC9099 (FAS) - (06/04)
Page: 11 of 11