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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320095
Report Date: 11/08/2023
Date Signed: 11/08/2023 11:02:02 AM


Document Has Been Signed on 11/08/2023 11:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:HAWTHORNE TERRACE CARE HOME, LLCFACILITY NUMBER:
198320095
ADMINISTRATOR:HAUF, MARYFACILITY TYPE:
740
ADDRESS:4760 W 123RD STTELEPHONE:
(201) 562-8622
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 11DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Zou Fen Hauf/AdministratorTIME COMPLETED:
11:00 AM
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On 11/8/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Zou Fen Hauf/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (14) residents ages 60 and above of which (6) non-ambulatory and (8) ambulatory. Facility has an approved hospice waiver for (6) patients.

The facility is a single-story home in a residential area. The facility has seven (7) bedrooms, one (1) staff room, four (4) restrooms (2) full baths, (1) shower, kitchen, (2) sitting areas, laundry area, attached garage and an outside sitting area whit shade.



LPA Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (5) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 #4 and #5 and smoke and carbon monoxide combo are all in operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 108.5°F, Bathroom #1:105.7°F, Bathroom #2:106.3°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC
FACILITY NUMBER: 198320095
VISIT DATE: 11/08/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (5) residents' service files, (5) staff personnel files and (5) Medication Administration Records (MAR) were maintained in order. First AID kit was checked. Last fire disaster drill was on: 5/14/2023.

LPA observed the facility's infection control practices. A copy of the liability insurance was provided to LPA during visit.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Zou Fen Hauf /Administrator.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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