197607682-3-1-2024-11-AS-SCIS-D4LVNK-20240423163516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 03/01/2024
Date Signed: 03/01/2024 05:08:13 PM

Substantiated

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:	0	CENSUS: 53	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	04:50 PM
MET WITH:	Crystal Pak		TIME COMPLETED:	04:51 PM

ALLEGATION(S):

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Residents are being charged more for rent than SSI rates.

INVESTIGATION FINDINGS:

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On 03/01/24, Licensing Program Analys (LPA), Wendy Gibbs, is changing findings to the above allegation this document supersedes the original dated 10/05/23.
On 10/05/23, Licensing Program Analyst (LPA), Perry Scott and Wendy Gibbs, conducted an unannounced subsequent complaint visit to the facility listed above. LPAs Scott and Gibbs met with Administrator, Crystal Pak, and explained the purpose of today's visit.
During today's visit, LPAs received additional documents pertinent to the investigation, conducted additional interview with Administrator and Resident (R12), and delivered findings for the allegations listed above.
On 08/11/23, the investigation consisted of the following: During today's visit LPA's conducted intrviews with staff (S1-S7) and Residents (R1-R11).
On 08/02/23, LPAs toured the facility. LPAs requested, reviewed, and received copies of pertinent documents including Resident and Staff Roster, ID Emergency Information, Physician’s Report, Dietician/Nutritionist Report, Pest Control Invoices, Admissions Agreements, List of all SSI Residents, Billing History of Residents, Activity Calendar, List of Incontinent Residents, Activity Director Application/Certification, and listing of Staff Training.

Substantiated

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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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-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: 03/01/2024

NARRATIVE

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Allegation: Residents are being charged more than SSI rates.

It is alleged the facility is charging residents more than the SSI rates.

LPA Gibbs and Scott received a list of residents that are receiving SSI and reviewed it against the Monthly Payment Log for June and July 2023. There are currently 22 residents who are receiving SSI, LPAs observed 20 residents are paying over the amount payable for basic services which is $1324.82. LPAs observed one resident is paying $1350.00. During interviews with the Administrator and Staff (A1 and S1) they were asked why R12 was paying above the SSI rate, two (2) out of two (2) stated that the Resident (R12), has been paying an additional $25.18 to make up a missed payment. Additionally, they stated as of September 2023, R12’s missed payment has been caught up. LPAs reviewed a copy of the agreement between R12 and the facility that states they will pay the additional amount till the missed payment was made up. LPA’s Gibbs and Scott received and reviewed a copy of the Monthly Payment Log for October which shows the amount paid as $1,324.82. Additionally, LPAs observed the remaining 19 residents are paying an additional $.05 over the SSI rate. During interviews staff A1 and S1 were unable to answer why they were paying above the amount payable for basic services. During interviews with Residents (R1-R11) they were asked how much they were paying in rent, sever (7) out of eleven (11) were unable to answer questions regarding the amount they were paying for rent. Residents R6-R9) were unable to answer due to a medical condition.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

Deficiency is cited on LIC9099-D page.

An exit interview could not be conducted due to facility closure.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/01/2024 Section Cited CCR 87464(e)	1 2 3 4 5 6 7	87464 Basic Services (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident	1 2 3 4 5 6 7	Due to facilities closure and dissolution of corporate entity, a POC could not be given at this time.
	8 9 10 11 12 13 14	This regulation was not met, based on record review the Administrator did not comply with this regulation and was charging SSI residents and an additional $.05.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

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