197607682-1-3-2024-11-AS-EDAT-CZ5SNM-20240103130146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 01/03/2024
Date Signed: 01/03/2024 01:01:53 PM

Document Has Been Signed on 01/03/2024 01:01 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	CRYSTAL PAK		FACILITY TYPE:	740
ADDRESS:	325 N HAYWORTH AVE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 58	DATE:	01/03/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	Bella Lee		TIME COMPLETED:	12:01 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 01/03/24, Licensing Program Analysts (LPAs) Ernand Dabuet and Lizeth Villegas conducted a POC inspection visit at this facility. LPA met with house manager Bella Lee and maintenance supervisor Juan Rossell and explained the purpose of the visit is to inspect the corrections cited on 12/18/23 for the pre-licensing inspection. During the inspection visit, LPA's reviewed the corrections for the following:

Smoke Detectors:

Smoke detectors in room #68 is not attached properly to the ceiling. - corrected 01/03/24

Physical Plant:

Rooms #13; #19, #44, #64, #66 and #80 cluttered - corrected: 01/03/24
Room #29, #61 (being used as storage) - corrected: 01/03/24
Room #23, #36, #43, #46, #73 and #83 no linens - corrected: 01/03/24
Room #23, #35, #7, #59 no furnishings - corrected: 01/03/24
Room #30 locked no key accessibility.- corrected: 01/03/24
Room #31 exposed hazardous chemical spray - corrected: 12/18/23
Room#11 obstruction bed blocking access to closet - corrected: 12/18/23
Room #35 no hot water faucet not operable - corrected: 12/27/23
Rooms #46, #83 and #84 window screens missing. corrected: 12/28/23
Room #39 no doorknob - corrected: 12/28/23
Room #25 and #34 molds along the wall surfaces - corrected: 12/28/23

Pest Control:

Room #20 (roaches) - corrected: 12/28/23
Room #21 (roaches) - corrected: 12/28/23
Room #22 (roaches) - corrected: 12/28/23
Room #24 (roaches) - corrected: 12/28/23

(Evaluation Report continue LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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 2

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: 01/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Pest Control

Room #25 (roaches) - corrected: 12/28/23
Room #34 (roaches) - corrected: 12/28/23
Room #35 (roaches) - corrected: 12/28/23
Room #36 (roaches) - corrected: 12/28/23
Room #85 (roaches) - corrected: 12/28/23

Staff Records:

Fingerprint Clearances Exceptions - (S2), (S3), (S7) - corrected: 01/03/24
Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders - (S3), (S4), (S5), (S7) - corrected: 01/03/24
Criminal Statement - (S3), (S7) - corrected: 01/03/24
Health Screening - (S3) - corrected: 01/03/24
TB Test - (S3) - corrected: 01/03/24
Education Verification - (S2), (S3), (S5) and (S7) - corrected: 01/03/24
Employee Rights - (S4), (S7) - corrected: 01/03/24

Resident Records:

Consent Forms - (R3), (R5) - corrected: 01/03/24
Safeguard for Property/Valuables - (R2), (R3), and (R4) - corrected 01/04/24
Personal Rights (R3) - corrected: 01/03/24

Based on record reviews and inspection of the facility all citations have been corrected timely and no civil penalties are issued.

An exit interview conducted with house manager Bella Lee and a copy of the report is provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2