<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 03/21/2024
Date Signed: 09/25/2024 10:29:43 AM

Unsubstantiated


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
03/14/2024 and conducted by Evaluator David Espana
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240314140250
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: 10DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
08:54 AM
MET WITH:Mercedes Espino, Caregiver TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff behavior is preventing a resident from sleeping
Staff do not prevent the residents from arguing
Staff did not prevent a resident from falling out of bed
Staff is retaliating against a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
****This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/21/2024.** On 03/21/2024 at 8:54 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint investigation visit for the allegation listed above and was greeted by Administrator Josephine Hauf.

Investigation consisted of the following: On 03/21/2024 LPA España explained the purpose of this visit is to gather information and conduct interviews with staff for the allegations mentioned above. Upon arrival at the facility, LPA España conducted a risk assessment at the front door. LPA España was granted access and allowed to enter the facility to conduct inspections.


LIC9099 Continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The investigation consisted of the following continued: A tour of the facility was conducted on 03/21/2024 at 10:23 am. LPA España interviewed Resident 1- Resident 5 (R1-R5). LPA España interviewed Staff 1-Staff 3 (S1-S3). LPA Espana requested and received the following documents: Staff and resident roster; SIR reports; dated weekly employee time schedule; RCFE license certificate; verification of first aid training; criminal record statement; verification of staff training; personal rights; client resident personal property and valuables; centrally stored medication and destruction record; identification and emergency information; physician's report; resident appraisal; admission agreement; home health agency (list of all who provide services to residents/contact information); daily notes/staff notes/facility notes (1-month records); records or procedures of eviction; records of all evictions (log records) of the past 1 month (30 days); records of diapers or pull-ups of all residents in the facility and other pertinent records associated with this complaint.

The investigation revealed the following:

Allegation: Staff behavior is preventing a resident from sleeping.

Administrator Josephine Hauf was interviewed by LPA España on 03/21/2024 at 9:07 am. Administrator stated that the night shift is managed by the Administrator and that staff do not prevent residents from sleeping. Administrator mentioned a ratio of 10 residents to 3 staff members, with herself covering the night shift. LPA España interviewed Resident 1- Resident 5 (R1-R5). LIC9099 Continued

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 LPA España interviewed Staff 1-Staff 3 (S1-S3). Of those interviewed, S1-S3 stated there were no issues with staff behavior or preventing a resident from sleeping. On 03/21/2024, Residents (R1-R5) were interviewed, with 3 out of 5 residents stating they had no issues with sleeping.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 allegations is Unsubstantiated.

Allegation: Staff do not prevent the residents from arguing.

On 03/21/2024, LPA España interviewed S1-S3. Of those interviewed, 3 out of 3 staff stated they stepped in to prevent residents from arguing and added that only one resident argues with them. On 03/21/2024 LPA España Interviewed R1-R5. Of those interviewed, 3 out of 5 residents had no issues with S1-S3, either during day or night shifts. 3 out of 5 residents also confirmed they did not engage in arguments with staff, nor did staff argue with them.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 allegations is Unsubstantiated. LIC9099 Continued

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff did not prevent a resident from falling out of bed.

On 03/21/2024, LPA España interviewed Staff 1-Staff 3 (S1-S3). Of those interviewed, 3 out of 3 stated facility takes precautions to prevent falls, and two staff added that one resident did fall out of bed after declining staff assistance.

Additionally, LPA España interviewed Resident 1- Resident 5 (R1-R5), of those interviewed 4 out of 5 had no issues with falls. Additionally,3 out of 5 residents also confirmed being checked by staff regularly.

On 03/21/2024, LPA España conducted records reviews at facility. Daily notes/staff notes/facility notes (1-month records), which indicated no falls for any of the residents in the period between February 21 to March 20, 2024.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 allegations is Unsubstantiated.


Allegation: Staff is retaliating against a resident.

On 03/21/2024, LPA España spoke to Administrator Josephine Hauf regarding the allegation, administrator Hauf stated that no residents were subjected to retaliation. LIC9099 Continued

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 3/21/2024 LPA España interviewed Resident 1- Resident 5 (R1-R5) and Staff 1-Staff 3 (S1-S3). On 03/21/2024, LPA España interviewed S1-S3 who stated they had not retaliated against residents. LPA España interviewed Resident 1- Resident 5 (R1-R5), of those interviewed 3 out of 5 stated they had seen not retaliatory behaviors fromss staff.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has not been met. Although the allegations 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 allegations is Unsubstantiated.

No were no deficiencies cited at the time of visit. An exit interview was conducted with Mercedes Espino, Caregiver and a hard copy was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Intentionally Blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20240314140250
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: 03/21/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Intentionally Blank
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: David Espana
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7