197607682-2-27-2024-11-AS-MVAO-D3BSEN-20240313134902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 02/27/2024
Date Signed: 02/27/2024 03:50:42 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/21/2023 and conducted by Evaluator Elvira Gonzalez

COMPLAINT CONTROL NUMBER: 11-AS-20231121084713

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:	0	CENSUS:	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:			TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not meet resident's incontinence needs.
Staff did not provide a safe and comfortable environment for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elvira Gonzalez attempted to conduct an unannounced subsequent complaint visit to the facility. Facility closed on 1/7/2024 so findings could not be delivered as there was no authorized agent available for a signature.

The investigation consisted of the following: On 11/27/2023, LPA Montoya toured the facility with Maintenance Supervisor, Juan Russell. LPA requested and obtained copies of the resident roster and staff roster. LPA requested copies of five residents’ (R1-R5) service records which include Physician’s Report, Appraisal/Needs and Services Plan and other pertinent records. LPA interviewed five staff (S1-S5), and three residents (S1-S3).

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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 3

Control Number 11-AS-20231121084713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2024

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not meet resident's incontinence needs.

It is alleged that staff did not meet resident's incontinence needs. On 11/27/2023 from 11:45 AM – 1:30 PM, LPA Montoya conducted interviews with five out of twelve staff (S1-S5) three out of fifty-six residents (R1-R3). Based on interviews conducted, five out of five staff and three out of three residents denied that staff did not meet resident’s incontinence needs. Based on records review of five residents, The physician’s reports of four out of five residents indicate that these residents have bowel/bladder impairments, while one out of five residents does not have incontinence needs. Staff assistance is addressed in the appraisals of the residents who have incontinence needs. Based on LPA’s observation during the visit, staff are constantly checking on residents. LPA did not observe any residents’ pants/clothes soaked with urine. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Allegation: Staff did not provide a safe and comfortable environment for residents.

It is alleged that staff did not provide a safe and comfortable environment for residents. On 11/27/2023 from 11:45 AM – 1:30 PM, LPA Montoya conducted interviews with five out of twelve staff (S1-S5) and three out of fifty-six residents (R1-R3). Based on interviews conducted, five out of five staff and three out of three residents denied that staff did not provide a safe and comfortable environment for residents. Based on records review of five residents, there are no incident reports about staff not providing a safe and comfortable environment to residents. Based on LPA’s observation during the visit, residents are quiet and comfortable. LPA did not observe any residents in distress. Based on information gathered, there is no sufficient evidence to corroborate the above allegation.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20231121084713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/27/2024

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	Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview could not be completed due to facility closure.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elvira Gonzalez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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