197607682-5-23-2025-11-AS-RORN-DHRKKH-20250618075820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 05/22/2025
Date Signed: 05/23/2025 08:05:34 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
05/14/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250514112407

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: 48	DATE:	05/22/2025
		UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Aldo Caesario Apostol		TIME COMPLETED:	02:32 PM

ALLEGATION(S):

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Facility has beg bugs.

INVESTIGATION FINDINGS:

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On May 22, 2025, the California Department of Social Services Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial visit to gather information regarding the above allegation. LPA met with Aldo Apostol, the Administrator, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of Interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #4 (S1-S4) and resident members #1 to #2 (R1-R2). List of documents reviewed/obtained Register of Faciltiy Residents (dated 05/22/25), Facility Staff Roster (dated 05/22/25), (R1)'s Physicians Report LIC 602 (dated 01/23/23 and 07/22/24), Admissions Agreement (dated 07/28/23), Department Health Care Services (DHCS) Individual Service Plan (dated 01/31/22), Medication Administration Record (MAR) (dated 08/01/23 through 08/31/23), and other records pertinent to this investigation.
(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

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-20250514112407

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: 05/22/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility has bed bugs.

The complaint details allege that the facility has a bed bug infestation. Reports indicate that on August 16, 2023, Resident #1 (R1) developed rashes and swelling due to bed bug bites, which resulted in hospitalization. The management of Hayworth Terrace was informed of the situation via text message but did not take any action. No additional information regarding this matter was provided.

On May 22, 2025, between 09:30 AM and 11:00 AM, the Department interviewed resident members identified as Resident #1 and Resident #2 (R1-R2). Two (2) of the two (2) resident members who were present in 2023 could not validate this allegation. (R1) stated they had not experienced any bed bugs in (R1’s) private room. (R2) said to have not seen any bed bugs or pests in (R2’s) room. (R1-R2) also denied seeing any pests in the facility's common areas.

On May 22, 2025, between 09:30 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of the four (4) could not corroborate this allegation. (S1) stated (R1), when first admitted, was in room #48 and later moved to room #87. (S1) said there was no evidence of bed bugs and no service request for pest treatments for both rooms. (S1) mentioned the facility had a contract with Pest Point Solutions, who came to the facility and did spray treatment regularly in 2023. (S2) stated that one of the primary care staff members for (R1) did not see any presence of bed bugs in (R1)’s room and did not observe any indication of skin problems. (S3-S4) could not validate this claim as both were hired after 2024 and were not presently working at the facility.

After reviewing the Physician's Report LIC 602A for (R1) (dated 01/25/23 and 07/22/24) and the Department Health Care Services (DHCS) Individual Service Plan (dated 01/31/22) revealed that (R1) had no history of skin condition or breakdown. A review of (R1) 's Medication Administration Record (MAR) (dated 08/01/23 through 08/31/23) indicated (R1) is taking (2) prescribed medications that can cause skin ulceration (ref: National Institute of Health NIH). Further review of invoices and contracts from Pest Point Solutions indicated that regular pest control treatment services were being performed regularly in 2023. No hospital records from Cedar Sinai are included in the file for (R1).
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20250514112407

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: 05/22/2025

NARRATIVE

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On May 22, 2025, the Departmental inspection was conducted in rooms #11, #26, #47, #48, #85, #86, and #87 and the common areas. The inspection found no bed bug infestation. Notably, rooms #48 and #87 were occupied by (R1), and the inspection revealed no signs of bed bugs in the baseboards, furniture, or mattresses.

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. while, he allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is determined Unsubstantiated.

An exit interview conducted with administrator Aldo Apostol and copies of the report provided.

The licensee Hayworth Properties, LLC. is served with this complaint investigation report through USPS Certified Mail on 05/22/25.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025

LIC9099 (FAS) - (06/04)

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