197607682-3-8-2022-11-AS-ASOO-CC6VNL-20220303153517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607682
Report Date: 03/03/2022
Date Signed: 03/08/2022 03:27:47 PM

Document Has Been Signed on 03/08/2022 03:27 PM - 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 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: 52	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Crystal Pak, Administrator		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA met with Grace Park, LVN and later met with Crystal Pak, administrator and the purpose of today’s visit was explained.

There are currently (51) residents in the facility. (43) residents are ambulatory and (9) are non-ambulatory. The facility is a 2 story beige building located in a residential neighborhood. It consists (72) bedrooms, (77) full bathrooms, shaded court yard, laundry area back of building, 3 TV rooms, 2 lounge areas, dining room, kitchen, storages rooms, and basement.

LPA and Juan toured the entire facility inside and out. Documents are posted as mandated. 1st floor bedrooms are occupied by residents and contain the mandated furniture. The 2nd floor has only 7 rooms being occupied by residents. All bedrooms contain the mandated furniture. The bathrooms are clean and operational. First aid kit is complete and with manual; smoke detectors are inter-connected and are monitored by fire department. The facility has 6 carbon monoxide detectors, smoke detector/fire alarm system and carbon monoxide were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. 3 Resident files and Medications are current and complete. 3 staff file were not complete and/or current. Ample supply of perishable and nonperishable food, hot water temperature is 114.6 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 8 fire extinguishers are fully charged. The facility has 2 elevators, (one is not operational, due to a power outage in the area. City is working to fix elevator.) the other elevator is operational. Exit, walkways and/or passageways, court yards are free of debris and/or hazards. The facility is in good repair.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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
	VISIT DATE: 03/03/2022

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During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, additional sanitation supplies are locked in the medication room. LPA observed staff wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and residents in shared room will be transferred to an empty room. The required postings throughout the facility. The facility has an approved Mitigation plan and posted. The resident’s temperatures are checked and logged once a day. Facility has not completed the FIT Testing for staff. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies and issued citations.

An exit interview was conducted with Grace Park, LVN and a copy of Report and Appeal Rights provided

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/08/2022 03:27 PM - 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: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited


	Deficient Practice Statement
1 2 3 4	87412 (a)(13)(A) - A signed statement regarding their criminal record history as required by Section 87355(d). This was not met as evidence by: Based on interviews and records facility personnel records were missing LIC 508 criminal record statement. Which poses a health and safety risk for residents in care.
	POC Due Date: 03/15/2022
	Plan of Correction
1 2 3 4	Administrator to provide a picture of the LIC 508 signed by 3 employees by email, fax, or text by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4	87211(a) - 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 interviews and reports the facility failed to report that one of their elevators was out of order. Which poses a potential health and safety risk for persons in care.
	POC Due Date: 03/25/2022
	Plan of Correction
1 2 3 4	Administrator to provide a copy of repair order or invoice from City of LA fin ished the repairs. By email, fax, or text by POC due date.

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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