197607682-3-17-2022-11-AS-JHAD-CCU2KP-20220324172816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 03/17/2022
Date Signed: 03/17/2022 12:15:34 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
02/17/2021 and conducted by Evaluator Ana Soto

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210217160807

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	197607682
ADMINISTRATOR:	HELEN PAK		FACILITY TYPE:	740
ADDRESS:	325 N. HAYWORTH AVENUE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS:	DATE:	03/17/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Grace Park, LVN		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained multiple falls while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA's) Ana Soto and Jeremiah Randle conducted a subsequent complaint investigation to deliver amended findings and decisions for the allegation listed above which supersedes findings dated 06/11/21. Today’s complaint investigation was conducted with Grace Park, LVN.

The investigation consisted of following: Interviews and Record reviews. On 02/26/21, LPA Soto interviewed Administrator Crystal Pak and Grace Park, LVN. On 06/01/21, interviewed Staff #3 & S#4 and interview residents R#1 - R#7 with Korean interpreter. On 03/07/22, LPA interviewed family member with Korean interpreter. LPA Soto requested and received following documents: Resident roster, Staff roster, Physician’s Report, and Appraisal/Needs and services, for R#1, R#2, & R#6.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

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-20210217160807

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: 03/17/2022

NARRATIVE

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Based on the LPA's investigation, the investigation revealed the following. For Allegation 1st – Resident sustained multiple falls while in care. The interviews with Administrator, S#3, & S#4, all stated that they have never seen R1 fall. Interviews with LVN, stated that she did recall R1 falling and they sent R1 to the hospital, but R1 has only falling once, no more falls have occurred. R#2 – R#7, some stated that they have not fallen and some stated that they do not know. R#1 could not understand or comprehend LPA's questions even with Korean interpreter. The facility does not maintain records on in house incidents or medical notes for the residents. There were no records for LPA to review and all the interviews did not concur with the above allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated

A exit interview was conducted with Grace Park, LVN, and a hard copy of report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana Soto	TELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022

LIC9099 (FAS) - (06/04)

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