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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:34:25 PM


Document Has Been Signed on 12/04/2023 04:34 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
EL SEGUNDO, 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: 58DATE:
12/04/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:34 AM
MET WITH:Lee Bella TIME COMPLETED:
02:45 PM
NARRATIVE
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On 12/04/23, Licensing Program Analysts (LPAs) Ernand Dabuet and Lizeth Villagas conducted an unannounced Case Management visit at this facility. Upon arrival, LPA conducted a risk assessment. LPA spoke with house manager Lee Bella who confirmed the facility has no COVID activity. LPA explained the purpose of the visit is to conduct a health and safety inspection in association with the "Decision Order" legal case # 669101401 discussed during an office visit on 11/13/23 with El Segundo Community Care Licensing Regional Office.

The Department conducted health and safety of the entire facility between 10:00 am through 11:20 am. The following rooms were inspected: #1, #4, #6, #8, #13, #11, #18, #19, #20, #27, #30, #31, #32, #33, #60, #62, #64, #68, #65, #74, #80, #84, #85, #86 were found to be in operational and within Title 22 regulations. The following rooms were empty: #2, #7, #22, #23, #24, #25, #26, #28, #29, #34, #35, #37, #40, #41, #43, #45, #46, and #48. The following rooms were identified with full bed rails: #8A/B, #10, #63, #67 and #87.

The following were observed during inspection and are being cited:
  • 87608(5)(B) Postural Supports - (7) residents identified with full bed rails with no physicians order
  • 87405(a) - Facility does not have a qualified administrator on staff
  • 87777(g) - Excluded former staff have been observed present at the facility after 11/13/23.
  • 1569.682(a)(2) - Transfer of resident upon forfeiture of license - no closure plan submitted to RO


The Department identify during health and safety inspection (7) residents with full bed rails and were not on hospice care nor had physician's order for approved bed rails. Interviews with staff verified the facility does not have a qualified administrator on staff. Interviews with staff verified former staff Crystal Pak who was excluded has been present and has failed to comply with the Department's exclusion order. The facility has not submitted a "Closure Plan" and failed to meet the agreed deadline discussed on 11/13/23 office meeting.
(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 12/04/2023 04:34 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
87608(5)(B)

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87608 - Postural Supports - (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited... receiving hospice...
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Licensee will adhere to the regulations and will ensure residents not on hospice care must not have full bed rails. Licensee will ensure to remove bed rails and proof of correction sent by fax 424-544-1016 El Segundo Regional office by 12/08/23
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This requirement is not met as evidence by:
Based on observation and record review, (7) resident had full bed rails and were not on hospice care with no medical prescription. This violation possesses a potential Health and Safety risk to residents in care.
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Type B
12/05/2023
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties - (a) All facilities shall have a qualified and currently certified administrator...

This requirement is not met as evidence by:
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Licensee will adhere to the regulations and will ensure to have a qualified administrator on staff. Licensee will notify CCLD and submit qualified administrator and proof of correction sent by fax 424-544-1016 El Segundo Regional office by 12/08/23
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Based on interviews and record review, The facility does not have a qualified administrator on staff. This violation possesses a potential Health and Safety risk 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: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/04/2023
NARRATIVE
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According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Lee Bella and a copy of report and appeal rights 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: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/04/2023 04:34 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
12/05/2023
Section Cited
CCR
87777(g)

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87777 - Exclusions (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.


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Licensee will adhere to the regulations and will ensure to comply with exclusion order and not have former staff present at the facility. Licensee will notify CCLD and submit written statement complying to Title 22 regulations and proof of correction sent by fax 424-544-1016 El Segundo Regional office by 12/05/23
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This requirement is not met as evidence by:
Based on interviews and record review, The licensee failed to comply with the exclusion order for former staff Cyrstal Pak has been present at the facility after 11/13/23. This violation possesses a potential Health and Safety risk to residents in care.
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*IMMEDIATE CIVIL PENALTY*

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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: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 12/04/2023 04:34 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2023
Section Cited
HSC
1569.682(a)(2)

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1569.682 Transfer of resident upon forfeiture of license or change in use of facility...(a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility...
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Licensee will adhere to the regulations and will ensure comply with the H&S 1569.682 and submit a "Closure Plan" to RO for approval. Licensee will send closure plan for correction sent by fax 424-544-1016 El Segundo Regional office by 12/06/23.
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This requirement is not met as evidence by: Based on observation and record review, the licensee has failed to submit a "Closure Plan" for approval to RO agreed deadline. This violation possesses a potential Health and Safety risk 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: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 12/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2023
LIC809 (FAS) - (06/04)
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