197607682-8-5-2022-11-AS-UCOL-CLDNUL-20221121094630

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 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: 54	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Grace Park, LVN		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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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 Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (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)

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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 Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (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)

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