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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 02/25/2022
Date Signed: 02/28/2022 06:34:41 AM


Document Has Been Signed on 02/28/2022 06:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
197607682
ADMINISTRATOR:CRYSTAL PAKFACILITY TYPE:
740
ADDRESS:325 N. HAYWORTH AVENUETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: DATE:
02/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Grace Park, LVNTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst, (LPA) Ana Soto conducted a monthly case management visit to the above facility. LPA was met by grace Park, LVN and Later spoke with Crystal Pak, Administrator via telephone and the purpose of the visit was explained.

LPA and Juan maintenance supervisor, toured the 2nd floor, med room, front office, lobby, and dining room. LPA Soto interviewed Administrator via telephone, Grace, and Juan. LPA cited for not reporting incident in the facility and Administrator not being at the facility enough to oversee daily operations of the facility. Citations were given due to NC conference.

An exit interview conducted with Grace Park, LVN and hard copy of report and Appeal Rights provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/28/2022 06:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited

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All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person.....This was not met as evidence by: Based on reports an interviews administrator does not spend enough time at the facility. Which poses a potential health, safety to persons in care.
Type B
03/04/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: This was not met as evidence by: Based on reports and interviews the facility does not report all incidents occuring at the facility. Which poses a potential health, safety to persons in care.

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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2