198320095-2-1-2023-11-AS-RORN-D3KLC8-20240321083754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 01/31/2023
Date Signed: 02/01/2023 08:33:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
01/23/2023 and conducted by Evaluator Lourdes Montoya

COMPLAINT CONTROL NUMBER: 11-AS-20230123121242

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: 9	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	JOSEPHINE HAUF/MARY HA		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is unsanitary.
Staff locked resident in their room.
Food services are inadequate.
Facility is odiferous.
Staff did not ensure that resident had adequate bedding.

INVESTIGATION FINDINGS:

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On 1/31/2023, Licensing Program Analysts (LPAs) Lourdes Montoya conducted an initial 10-day complaint visit at this facility to deliver complaint investigation findings. LPA Montoya called and conducted a risk assessment with Administrator Steven Ha who confirmed the facility is free of Covid-19 infection. LPA met with Administrator Josephine Hauf and explained the purpose of the visit was explained. Mary Ha/Licensee arrived later and joined the visit.

The investigation consisted of the following: LPA Montoya conducted a tour of the inside and outside grounds of the facility with Administrator Josephine Hauf. LPA interviewed staff and residents. LPA requested and obtained a client roster, staff roster, food menu, Resident #1's service records and other pertinent records.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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 3

Control Number 11-AS-20230123121242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2023

NARRATIVE

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INVESTIGATIONS REVEALED:

Allegation: Facility is unsanitary.

It is alleged facility is unsanitary. LPA interviewed two residents (R2-R3) and three staff (S1-S3). LPA attempted to interview one resident (R1) but R1 had already moved out of the facility. LPA attempted to interview R1 by telephone but R1 refused to be interviewed. Based on interviews conducted with residents (R2-R3) and staff (S1-S3), the facility is not unsanitary. R3 stated staff always clean the facility including R3's bedroom. S1, S2 and S3 stated staff clean the entire facility every day. Based on LPA’s observation, the entire facility is not unsanitary.

Allegation: Staff locked resident in their room.

It is alleged staff locked resident in their room. LPA interviewed two residents (R2-R3) and three staff (S1-S3). LPA attempted to interview one resident (R1) but R1 had already moved out of the facility. LPA attempted to interview R1 by telephone but R1 refused to be interviewed. Based on interviews conducted with residents (R2-R3) and staff (S1-S3), staff do not lock residents in their bedroom. R3 stated R3 keeps the bedroom locked but staff can unlock it in case of emergency. S1, S2 and S3 stated some residents prefer to lock their bedrooms but staff have keys to open the rooms in case of emergency. Based on LPA’s observation, the door locks can be locked and unlocked inside the bedroom and staff can open the lock with a key or a coin or a fingernail from the outside of the bedroom.

Allegation: Food services are inadequate.

It is alleged food services are inadequate. LPA interviewed two residents (R2-R3) and three staff (S1-S3). LPA attempted to interview one resident (R1) but R1 had already moved out of the facility. LPA attempted to interview R1 by telephone but R1 refused to be interviewed. Based on interviews conducted with residents (R2-R3) and staff (S1-S3), food services are adequate. R2 stated staff serve residents with abundant and delicious food. R3 stated the food served in this facility is more than adequate, food service is good and prompt. S1, S2 and S3 stated food services are adequate. S1 stated staff always give extra food to residents and no residents have ever complained about food services. S2 stated the facility serve residents with three meals and two snacks. S3 stated staff provide variety of food and they give residents the food they want. Based on LPA’s observation, food service is prompt and staff provide more than adequate food.

REPORT CONTINUED IN LIC 9099C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20230123121242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/31/2023

NARRATIVE

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Allegation: Facility is odiferous.

It is alleged facility is odiferous. LPA interviewed two residents (R2-R3) and three staff (S1-S3). LPA attempted to interview one resident (R1) but R1 had already moved out of the facility. LPA attempted to interview R1 by telephone but R1 refused to be interviewed. Based on interviews conducted with residents (R2-R3) and staff (S1-S3), the facility is not odiferous. R2 stated the facility is always clean. R3 stated R3 never smelled any unpleasant or bad smell in the facility. S3 stated the facility smells good and a lot of visitors appreciate the smell inside the facility. Based on LPA’s observation, the facility is not odiferous.

Allegation: Staff did not ensure that resident had adequate bedding.

It is alleged staff did not ensure that resident had adequate bedding. LPA interviewed two residents (R2-R3) and three staff (S1-S3). LPA attempted to interview one resident (R1) but R1 had already moved out of the facility. LPA attempted to interview R1 by telephone but R1 refused to be interviewed. Based on interviews conducted with residents (R2-R3) and staff (S1-S3), staff did ensure that resident had adequate bedding. R2 stated staff change the beddings three to four times a week. R3 stated R3 has comfortable and adequate beddings. S3 stated staff change the beddings two to four times or even every day if needed. Based on LPA’s observation, the facility has plenty of clean beddings.

Based on information gathered, the department did not find sufficient evidence to support the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of the report was provided to Administrator Josephine Hauf.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

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