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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 08/11/2021
Date Signed: 08/11/2021 02:02:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2020 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20201007082200
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
197607682
ADMINISTRATOR:HELEN PAKFACILITY TYPE:
740
ADDRESS:325 N. HAYWORTH AVENUETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 65DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Julita Arriola-StaffTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff withheld resident's P&I money
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/11/2021 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a subsequent complaint investigation at above facility. LPA arrived at facility and was greeted by staff Julita Arriola . LPA explained the purposed of the visit was to deliver findings for the allegations listed above and was granted access to the facility.

The investigation consisted of the following:

On 10/16/2020 LPA Kourtney Williams initiated complaint investigation telephonically with facility. LPA interviewed administrator and conducted a plant inspection via zoom. On 5/4/2021 LPA Cifuentes completed interviews with resident 1-resident 8 (R1-R8) and staff 1-staff 5(S1-S5). On 7/1/2021 LPA Cifuentes reviewed facility records, re-interviewed resident 1 and staff 6-8 (S1-S8). On 8/11/2021 LPA Cifuentes conducted a tour of facility grounds. LPA requested and received the following information: Staff roster, client roster, facility financial records and admissions agreements for resident 1-resident 4.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2020 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20201007082200

FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
197607682
ADMINISTRATOR:HELEN PAKFACILITY TYPE:
740
ADDRESS:325 N. HAYWORTH AVENUETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 65DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Julita Arriola-Staff TIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility charging more than the basic rate for SSI resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/11/2021 Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a subsequent complaint investigation at above facility. LPA arrived at facility and was greeted by staff Julie Arriola . LPA explained the purposed of the visit was to deliver findings for the allegations listed above and was granted access to the facility.

The investigation consisted of the following:

On 10/16/2020 LPA Kourtney Williams initiated complaint investigation telephonically with facility. LPA interviewed administrator and conducted a plant inspection via zoom. On 5/4/2021 LPA Cifuentes completed interviews with resident 1-resident 8 (R1-R8) and staff 1-staff 5(S1-S5). On 7/1/2021 LPA Cifuentes reviewed facility records, re-interviewed resident 1 and staff 6-8 (S1-S8). On 8/11/2021 LPA Cifuentes conducted a tour of facility grounds. LPA requested and received the following information: Staff roster, client roster, facility financial records and admissions agreements for resident 1-resident 4.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20201007082200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 08/11/2021
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
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31
32
Allegation: Facility charging more than the basic rate for SSI resident

The complainant alleges that R1 is on SSI and was not charged SSI rate by facility. Per administrator Crystal Pak, she was unaware of how much the facility rent was or what the SSI rate should be. She also stated that residents’ families or referring case workers told the facility if the resident had SSI or another form of income. LPA also spoke to previous administrator Helen Pak, who stated the facility was unaware that R1 had SSI until they returned from skilled nursing and told administrator they had been approved for the Assisted Living Waiver Program. LPA reviewed the admissions agreements for (R1-R4). Page 7 of the admissions agreement does not admit the funding source for any of the admissions agreements reviewed nor does it indicate the residents refused to disclose their income sources. LPA received financial records from the facility dating January 2020 to April 2020, showing that R1 had paid $1700 for rent. The 2020 SSI rate is $1069.37.


Based on information gathered and service records reviewed, the department found sufficient evidence to support the allegation mentioned above.

Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of "Facility charging more that the basic rate for SSI resident" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Staff Julita Arriola and a hard copy was provided via email.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20201007082200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87507(g)(3)(F)
1
2
3
4
5
6
7
Admissions Agreement
Admission agreements shall specify the following...Payment provisions, including the following...Funding source, provided that the resident may refuse to disclose such source.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will go through all admissions agreements and make sure that funding source information is verified, put into admissions agreement and signed by resident.
8
9
10
11
12
13
14
Through records review and interview, on 8/11/2021 LPA Cifuentes observed that admissions agreements for R1-R4 did not include a funding source. This is a potential health and safety concerns to the residents in care.
8
9
10
11
12
13
14
Type B
08/31/2021
Section Cited
CCR
87464(e)
1
2
3
4
5
6
7
Basic Services
...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.
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility will reimburse R1 for over payments made from 3/15/2018 to 4/20/2020 according to yearly SSI rate. Proof of reinbursement will be sent to CCL by POC due date
8
9
10
11
12
13
14
Through records review and interview, on 8/11/2021, LPA found that facility had charged SSI resident R1, charging $1700 from date of admission on 3/15/2018 to 4/20/2020, instead of set SSI rate. This is a potential health and safety concern to the residents in care.
8
9
10
11
12
13
14
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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20201007082200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87405(D)
1
2
3
4
5
6
7
Administrator - Qualifications and Duties
The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply...Knowledge of and ability to conform to the applicable laws, rules and regulations.
This regulation is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will provide CCL with SSI rates for 2018, 2019, 2020 and 2021 as well as a statement by administrator that they have reviewed and understood Regulation 87507 and facility admissions agreement. Due to CCL by POC due date.
8
9
10
11
12
13
14
Through interviews LPA learned that administrator failed to know SSI rates or details of facility admissions agreement. This is a potential risk to the health and safety of residents in care.
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 AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20201007082200
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 08/11/2021
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 investigation revealed the following:

Allegation: Facility staff withheld resident's P&I money

The complainant states that during their stay at the facility, resident never received their monthly P&I money. LPA Cifuentes spoke with administrator Crystal Pak who stated facility does not handle residents P&I money. Per facility admissions agreement page 3, the facility does not provide assistance with or management of residents money. LPA spoke with residenst (R2-R7) who stated the facility did not handle their P&I. LPA spoke with staff (S1 to S9) and was told facility does not handle residents P&I.



Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of service records, incident report, and interviews conducted and found no evidence to support the allegations: "Facility staff withheld residents P&I money."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 was conducted with Julita Arrivola and a copy of the report was provided by email.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6