197607682-3-18-2024-11-AS-UCOL-D4EMFF-20240417093414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 03/18/2024
Date Signed: 03/18/2024 10:48:43 AM

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
10/30/2023 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231030163649

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: 0	DATE:	03/18/2024
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Juan Rossell, building manager		TIME COMPLETED:	10:57 AM

ALLEGATION(S):

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Facility does not have an adequate amount of food supply.

INVESTIGATION FINDINGS:

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On 03/18/24 Licensing Program Analyst (LPA) Mario Leon completed this report to provide findings for the above allegation from an investigation that was conducted on 11/06/23.
On 03/18/24 LPA was met by Juan Rossell, building manager, and the purpose of the visit was explained.
The investigation consisted of the following:
On 11/06/23, Licensing Program Analyst (LPA) Mario Leon and Long-Term Care Ombudsman (LTCO) Jaime Cortes conducted a joint 10-day complaint investigation at the facility listed above. LPA and LTCO met with Crystal Pak, Administrator, and explained the purpose of the visit was to investigate the allegation listed above.
LPA and LTCO toured the facility, mainly focused on the food storage areas and kitchen. LPA requested and obtained copies of the following documents: Resident and Staff Roster, Admission agreement, Pest Control Invoices, Weekly Menus for past two weeks and requested food delivery receipts. LPA interviewed nine (9) of fifty (50) residents and interviewed five (5) out of twenty-five (25) staff.
Report Continues, see LIC9099C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231030163649

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: 03/18/2024

NARRATIVE

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The investigation revealed the following:

Regarding the allegation: "Facility does not have an adequate amount of food supply.". It has been alleged that the quality and quantity necessary to meet the needs of the residents does not meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.

Between 10:00 and 10:30AM, on 11/06/23, LPA and LTCO observed one residentially sized refrigerator which contained at least 1 days’ worth of perishable food. Between 11:10 and 11:15AM, on 11/06/23, LPA and LTCO observed one large pantry which contained at least 5 days’ worth of non-perishable food. Between 2:15 and 2:20PM, on 11/06/23, LPA and LTCO observed one commercially sized freezer, which contained at least 2 days’ worth of perishable food and 7 days’ worth of non-perishable food.

Interviews revealed that 5 out of 5 staff not have not agreed with the above allegation. Three (3) out of 9 residents have agreed with the above allegation, while 5 out of 9 residents did not agree with the allegation. Additionally, one (1) resident was unconcerned about the amount of food being provided.

Record reviews revealed that the food being purchased for, and provided to the facility was at least 2 days' worth of perishable and 7 days' worth of non-perishable food, which met the recommended dietary allowances provided by the Food and Nutrition Board of the National Research Council.

Based on LPA’s observations, record reviews and interviews conducted, the preponderance of evidence standard has not been met.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

An exit interview was conducted with Juan Rossell, building manager, and a copy of this report has been provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024

LIC9099 (FAS) - (06/04)

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