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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 02/02/2022
Date Signed: 02/02/2022 03:38:38 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220124115553
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: 70DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julie ArriolaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Facility has bed bugs
INVESTIGATION FINDINGS:
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13
On 2/1/22 Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint investigation for the above listed allegations. LPA met with Julita Arriola, the facility Medical Technician and the purpose of the visit was explained.

The investigation consisted of the following: On 2/1/22 LPA Brown conducted an interview with medical technician and staff #2-6. LPA toured the physical plants 1st and 2nd floors bedrooms. LPA also requested the following documents and reviewed: Client & Staff Roster, Pest Control invoices, housekeeping schedule, Residents #1 admissions agreement, physician reports, appraisals & needs & service, staff bathing schedule and incident reports
.
The investigation revealed the following:

Regarding allegation: Facility has bed bugs.

LIC 9099-C is on the next page
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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
Control Number 11-AS-20220124115553
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
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 02/02/2022
NARRATIVE
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On 2/2/22 LPA Conducted interview with staff #1-6, regarding the above allegation. 2 out of 6 staff stated they have seen a few bed bugs in residents bedroom on their beds. Staff #1-6, stated pest control comes to the facility once a month for monthly services. Staff #1-6 stated housekeeper clean residents room daily. LPA toured Resident R#1’s bedroom and notice bed bugs on the comforter and the sheets. LPA conducted interviews with R#1-#3 and 2 out of one resident stated they been having bed bugs for years. LPA was provided pest control invoices for 2 months. Based on interviews and findings the above allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20220124115553
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
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Administrator will outline a plan on how they will make sure the facility is free and clear from bed bugs. They will also send pictures of R1's bedroom to CCLD by POC due date.
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Based on LPA's observation and interviews conducted, Administrator did not ensure Resident R#1's bedroom free from bed bugs. This is a potential health and safety risk to clients 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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2022 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220124115553

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: 70DATE:
02/02/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julie Arriola TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident hygiene needs are not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/1/22 Licensing Program Analyst (LPA) Martessa Brown conducted a subsequent complaint investigation for the above listed allegations. LPA met with Julita Arriola, the facility Medical Technician and the purpose of the visit was explained.

The investigation consisted of the following: On 2/1/22 LPA Brown conducted an interview with medical technician and staff #2-6. LPA toured the physical plants 1st and 2nd floors bedrooms. LPA also requested the following documents and reviewed: Client & Staff Roster, Pest Control invoices, housekeeping schedule, Residents #1 admissions agreement, physician reports, appraisals & needs & service, staff bathing schedule and incident reports
.
The investigation revealed the following:

Regarding allegation: Resident Hygiene needs are not being met

LIC 9099-C is on the next page
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20220124115553
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
MONTEREY PARK, CA 91754
FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
VISIT DATE: 02/02/2022
NARRATIVE
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On 2/2/22 LPA Conducted interview with Julita Arriola-Medical Technician, regarding the above allegation. She stated resident doesn't want to take a baths and they try to convince the resident. She stated resident use to be independent and could take baths. On 2/2/22 LPA conducted interview with R#1, stated doesn't get baths by caregivers in a long time. R1 also stated only cleans up with witchhazel. LPA reviewed R#1 Physicians reports and needs & services indicated R1 does need assistance with bathing. Based Based on interviews and documents the above allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was furnished.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20220124115553
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
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 197607682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited
CCR
87459(a)(1)
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2
3
4
5
6
7
87459 Functional Capabilities
(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities...
(1) Bathing, including need for assistance:

This requirement was not met as evidenced by:
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Administrator will outline a plan on how they will make sure the R1's are being met to ensure personal assistance needs are being met. Administrator will review regulation and provide to CCLD by POC due date.
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Based on observation and interviews conducted, Administrator did not ensure R1's was provided personal assistance and bathing needs were being met.
This is a potential health and safety risk to clients 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: Martessa BrownTELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6