197607682-12-18-2023-11-AS-SCIS-D4LVNL-20240423163516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 12/18/2023
Date Signed: 12/18/2023 03:51:03 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230724120911

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	CRYSTAL PAK		FACILITY TYPE:	740
ADDRESS:	325 N. HAYWORTH AVENUE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 58	DATE:	12/18/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Bella Lee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility residents are not being given their choices in what home health or hospice agencies they use.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/18/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted a visit to deliver the findings of the complaint investigation. LPA met with Facility Manager, Bella Lee, and explained the purpose of today's visit.
During today's visit LPA toured the facility.

On a previous visit, on 08/11/23, Licensing Program Analysts (LPA), Wendy Gibbs and Perry Scott, conducted a 10-day complaint visit at the facility listed above. LPAs met with Administrator, Crystal Pak, and the purpose of todays visit was explained.

During the visit on 08/11/23 LPA's conducted intrviews with staff (S1-S7) and Residents (R1-R11). LPA's toured the facility and receiveed pertinent documents related to the investigation.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 11-AS-20230724120911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 197607682
	VISIT DATE: 12/18/2023

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

The original LIC9099-C dated 12/18/23, is being amended. The revised LIC9099-C dated 03/01/22 will supersede the original document.

Allegation: Facility residents are not being given their choices in what home health or hospice agency they use.

It is alleged the facility uses Excellent Home Health and Saint Montserrat Hospice and that residents are not receiving care from hospice staff, only facility staff.During interviews with Staff A1 and S1 were asked if residents get their choice of Hospice or Home Health Agencies, two (2) out of two (2) stated the residents get to choose which hospice and/or home health agency they use. Staff A1 and S1 stated they do have a few companies they recommend, but the choice is the residents or their responsible family. When residents (R1-R11) were asked if they get a choice for Home Health or Hospices agencies, seven (7) out of eleven (11) were not sure. Residents (R6-R9) were unable to answer due to a medical condition. During resident file review, LPA observed the residents on Hospice and Home Health were using different agencies and three residents were using a Hospice company that is not recommended by the facility. LPA reviewed the Hospice folders and saw updates from the hospice nurses who make regular visits. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were cited.

An exit interview could not be conducted due to facility's closer.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
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

LIC9099 (FAS) - (06/04)

Page: 2 of 2