198320095-2-20-2024-11-AS-JHAD-D2X3MT-20240229172253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:35:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240213161521

FACILITY NAME:	HAWTHORNE TERRACE CARE HOME, LLC		FACILITY NUMBER:	198320095
ADMINISTRATOR:	HAUF, MARY		FACILITY TYPE:	740
ADDRESS:	4760 W 123RD ST		TELEPHONE:	(201) 562-8622
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	14	CENSUS: 10	DATE:	02/20/2024
		UNANNOUNCED	TIME BEGAN:	10:04 AM
MET WITH:	Administrator Zuofen "Josephine" Hauf		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility staff failed to provide resident with a refund.

INVESTIGATION FINDINGS:

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On 02/20/24 Licensing program analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegation above. LPA met with Administrator Zuofen "Josephine" Hauf as the purpose of today's visit was explained.

The investigation consisted of the following: On 02/20/24 LPA interviewed Administrator (AD), and obtained copies of the following for R1; Admission agreement, admission record, emergency I.D. form, POLST form, copy of bank statement for Direct deposit dated 02/01/24, copy of communication with CCA from ALW program, attempted communication with family, and a copy of SSI payment rates.

It is being alleged that facility staff received R1 Social Security Income (SSI) check for the month of February in the amount of $1575.07. According to the Complainant R1 did no longer resided at the facility as of January. The complainant stated R1 is unable to move into another facility because Hawthorne Terrace kept his rent check for February. On 2/20/24 at 10:00am LPA Villegas interviewed the

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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-20240213161521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 02/20/2024

NARRATIVE

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Administrator (AD) regarding the allegation and AD confirmed receiving R1 SSI check for the month of February in the amount of $1575.07 was direct deposited into the facility account. AD stated there was no refund provided as R1 owed Hawthrone Terrace $2,648 dollars for past due rent for the Month of December 2023 and January 2024. AD continued to report that the SSI check received via direct deposit was for $1,575.07 which only covered a part of the debt owed, Per AD R1 still owes $1,073 but AD is forgetting about the remaining balance. On 2/20/2024 at 11:00am, LPA Villegas conducted a file review of R1 file and observed an admission agreement dated 10/30/2023 which revealed R1 rent rate would be $1384.82 and indicates R1 source of income as SSI and that the residents participates in the Assisted Living Waiver Program. LPA review invoices for October 2023-January 2024. LPA did not observe an invoice for the month of February but observed an invoice for December 2023 and prorated fees showing R1 February 2024 SSI check was applied for past overdue rent.

Based on evidence gathered through the course of the investigation the Administrator used R1 SSI check for February rent not for its intended purpose and did not reach out to the Social Security Information for guidance since R1 no long resides at the facility.

Based on LPAs interviews which were conducted and records review that were reviewed, 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 9099D.

Exit interview conducted with the Administrator, appeal rights explained and copy of this report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240213161521

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/27/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities...To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination	1 2 3 4 5 6 7	Administrator should reach out to the Social Security Administration regarding R1 February 2024 check. Administrator shall develop a plan to comply with Title 22 Regulations to the department by POC due date.
	8 9 10 11 12 13 14	Based on interview and records review the Licensee did not comply with the section above. License kept R1 February 2024 SSI check although R1 moved out of the facility in January 2024. As of 2/20/2024, the Licensee has not returned the monies to R1 or contacted SSA. This poses a personal rights risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC9099 (FAS) - (06/04)

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