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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 12/18/2023
Date Signed: 12/19/2023 08:54:29 AM


Document Has Been Signed on 12/19/2023 08:54 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 58DATE:
12/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Bella Lee TIME COMPLETED:
03:59 PM
NARRATIVE
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On 12/18/23, Licensing Program Analysts (LPAs) Ernand Dabuet, Lizeth Villegas, Wendy Gibbs, and Alfonso Iniguez conducted a case management inspection visit at this facility. LPAs met with house manager Bella Lee and explained the purpose of the visit. During an inspection visit, LPAs observed the following deficiencies:

Smoke Detectors:
Smoke detectors in room #68 is not attached properly to the ceiling.

Physical Plant:
Room #31 exposed hazardous chemical spray
Room#11 obstruction bed blocking access to closet
Room #35 no hot water faucet not operable
Rooms #46, #83 and #84 window screens missing.
Rooms #13; #19, #44, #64, #66 and #80 cluttered
Room #29, #61 (being used as storage)
Room #23, #36, #43, #46, #73 and #83 no linens
Room #23, #35, #7, #59 no furnishings
Room #39 no doorknob
Room #25 and #34 molds along the wall surfaces
Room #30 locked no key accessibility.

(Evaluation Report continue LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 12/18/2023
NARRATIVE
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Pest Control:
Room #20 (roaches)
Room #21 (roaches)
Room #22 (roaches)
Room #24 (roaches)
Room #25 (roaches)
Room #34 (roaches)
Room #35 (roaches
Room #36 (roaches)
Room #85 (roaches)

Staff Records:
Fingerprint Clearances Exceptions - (S2), (S3), (S7)
Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders - (S3), (S4), (S5), (S7)
Criminal Statement - (S3), (S7)
Health Screening - (S3)
TB Test - (S3)
Education Verification - (S2), (S3), (S5) and (S7)
Employee Rights - (S4), (S7)
Missing File - (S1), (S8)

Resident Records:
Consent Forms - (R3), (R5)
Safeguard for Property/Valuables - (R2), (R3), and (R4)
Personal Rights (R3)

(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 12/18/2023
NARRATIVE
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Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8,

Deficiencies are issued and an exit interview is conducted with Bella Lee. A copy of this report, appeal rights, and civil penalty were provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/19/2023 08:54 AM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2024
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 make all the required repaires for each resident rooms. POC due date of 01/09/24 and shall be submitted to LPA ernand.dabuet@@dss.ca.gov
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Based on observation, the licensee did not comply with this section. LPA observed roaches, cluttered rooms, and mutiple resident's room requiring repairs (see LIC 809). This poses a potential health, safety, or personal rights risk to persons in care.
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*Repeat Violation*
Type B
01/09/2024
Section Cited
CCR87307(3)(c)

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87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance... cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit ... The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.
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Administrator agrees to ensure all resident rooms have the essential required furninshings per Title 22. POC due date of 01/09/24 and shall be submitted to LPA ernand.dabuet@@dss.ca.gov
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with this section. LPA observed muliptle resident rooms missing linens. (see LIC 809). 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: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2023 08:54 AM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
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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Administrator will ensure that all hazardous chemicals and sharp objects 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 LPA (by email) as proof of correction by POC due date 12/19/23 at perry.scott@dss.ca.gov. ttendance for training will be submitted to
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Based on observation, the licensee did not comply with the section cited above. LPAs observed room #31 hazadrous chemical spray exposed and unattended. This poses a potential risk to the health and safety of residents.
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*Repeat Violation*
Type B
01/09/2023
Section Cited
CCR87412(a)(1-13)

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87412 Personnel Records
a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:....
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Administrator will review 87412 Personnel Record and send complete file for each employee. Proof of correction sent by fax 424-544-1016 to El Segundo Regional office by 01/09/23.
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This requirement was not met as evidence by: Based on record review, all staff had incomplete records and missing required forms. This violation poses a potential health and safety to residents 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: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 12/19/2023 08:54 AM - 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2024
Section Cited
CCR
87506(b)(1-16)

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87506 Resident Records (b) Each resident’s record shall contain at least the following information: Resident's legal name and preferred name, as indicated by the resident....
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Administrator will review 87506 Resident Records and send complete file for each employee listed on LIC 809.
Proof of correction sent by fax 424-544-1016 to El Segundo Regional office by 01/09/23.
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This requirement was not met as evidence by: Based on record review, resident R2, R3, R4, & R5 had incomplete records and missing required forms. This violation poses a potential health and safety to residents 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: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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