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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607682
Report Date: 08/05/2022
Date Signed: 08/05/2022 05:17:55 PM

Unsubstantiated


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
07/26/2022 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220726101814
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: 54DATE:
08/05/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Grace Park, LVNTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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9
Staff not meeting resident needs.
Resident was not provided medical care in a timely manner.
Staff inappropriately touched resident.
INVESTIGATION FINDINGS:
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On 08/05/22 Licensing Program Analyst (LPA) Antonia Alvizar conducted an initial an unannounced complaint visit at this facility. LPA was greeted by Grace Park, LVN. LPA explained the purpose of today's visit.

The investigation included the following; A review of the Resident roster, Staff roster. Interviews were conducted with residents #1- #5 (R1-R5) and Staff #1- #3 (S1-S3). A tour of the facility physical plant. LPA also conducted review of R#1 medical review.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
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 2
Control Number 11-AS-20220726101814
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: 08/05/2022
NARRATIVE
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Continuation from LIC 9099

The investigation revealed the following: Regarding the allegation “Staff not meeting resident needs.” During interviews conducted, 0 out of 5 residents agreed with the allegation. 5 out of 5 residents disagreed with the allegation, resident R1 stated “No, they alright, one girl she takes her time taking care of me.” 3 out of 3 staff interviewed disagreed with the allegation staff S1 stated “No, all staff members help all the residents.” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”


Regarding the allegation “Resident was not provided medical care in a timely manner.” During interviews conducted, 0 out of 5 residents agreed with the allegation. 5 out of 5 residents disagreed with the allegation, resident R1 stated “No, I went to the doctor and got X-Rays on my feet.” 3 out of 3 staff interviewed disagreed with the allegation staff S2 stated “No, I help all residents by grooming every morning and take them a shower after breakfast.” “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”


Regarding the allegation “Staff inappropriately touched resident.” During interviews conducted, 0 out of 5 residents agreed with the allegation. 5 out of 5 residents disagreed with the allegation, resident R1 stated “No, staff is good. I have no problems with staff.” 3 out of 3 staff interviewed disagreed with the allegation staff S2 stated “No, staff don’t touch resident inappropriate”. “Although the allegation may have happened or is valid, there is not preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.”


No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Grace Park.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2