198320095-1-10-2024-11-AS-RORN-D3KLC7-20240321083753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 01/10/2024
Date Signed: 01/10/2024 12:45:39 PM

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
01/23/2023 and conducted by Evaluator Felisa Shirley

PUBLIC

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: 11	DATE:	01/10/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Mercedes Espino, Caregiver		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Facility retained a resident with a higher level of needs.
Staff did not seek medical attention for resident in a timely manner.
Staff did not provide resident with a copy of their Admissions Agreement.
Staff did not ensure that resident was showered.
Staff did not ensure that resident was advised of his personal rights.
Staff did not ensure that resident was provided with comfortable living accomodations.

INVESTIGATION FINDINGS:

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On 1/10/23, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent complaint visit at this facility to deliver complaint investigation findings. LPA met with Caregiver Mercedes Espino and explained the purpose of the visit.

The investigation consisted of the following: On 1/31/2023, LPA Lourdes Montoya conducted a tour of the inside and outside grounds of the facility with Administrator Josephine Hauf. LPA interviewed two out of nine residents and three out of six staff. Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. LPA requested and obtained a client roster, staff roster, food menu, Resident #1's service records and other pertinent records. On 2/6/2023, LPA Montoya conducted a telephone interview with one witness.

Investigations revealed the following:

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

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 4

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 01/10/2024

NARRATIVE

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Allegation: Facility retained a resident with a higher level of needs.

It is alleged that facility retained a resident with a higher level of needs. On 1/31/2023 between 11:05 am - 1:30 pm, LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3). Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted with two residents (R2-R3), three staff (S1-S3) and one witness (W1), the facility did not retain a resident with a higher level of needs. Based on records review, the department received an incident report about R1’s medical emergency on 1/17/23 but it does not indicate that R1 requires a higher level of care/needs when R1 returned to the facility on 1/18/23. LPA did not observe any residents requiring higher level of care. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Allegation: Staff did not seek medical attention for resident in a timely manner.

It is alleged that staff did not seek medical attention for resident in a timely manner. On 1/31/2023 between 11:05 am - 1:30 pm. LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3). Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted, two residents (R2-R3), three staff (S1-S3) and one witness (W1) denied that staff did not seek medical attention for resident in a timely manner. Based on records review, the department received an incident report about R1’s medical emergency on 1/17/23 which indicates that facility staff called 911 due to a medical emergency. Another incident report was submitted to the department regarding R1’s medical emergency on 1/23/23 and 911 was called. LPA did not observe any medical emergency during the visit. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 01/10/2024

NARRATIVE

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Allegation: Staff did not provide resident with a copy of their Admissions Agreement.

It is alleged that staff did not provide resident with a copy of their Admissions Agreement. On 1/31/2023 between 11:05 am - 1:30 pm. LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3). Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted, two residents (R2-R3), three staff (S1-S3) and one witness (W1) denied staff did not provide resident with a copy of their Admissions Agreement. Based on LPA’s records review and observation, the facility has an Admission Agreement for R1 signed by the POA. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Allegation: Staff did not ensure that resident was showered.

It is alleged that staff did not ensure that resident was showered. On 1/31/2023 between 11:05 am - 1:30 pm. LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3). Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted, two residents (R2-R3), three staff (S1-S3) and one witness (W1) denied that staff did not ensure that resident was showered. Based on records review, the facility daily care log shows R1 had showers/bed baths on 1/2/23, 1/9/23,1/14/23, 1/16/23, and 1/19/23. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Allegation: Staff did not ensure that resident was advised of his personal rights.

It is alleged that staff did not ensure that resident was advised of his personal rights. On 1/31/2023 between 11:05 am - 1:30 pm. LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3).

Con'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
	VISIT DATE: 01/10/2024

NARRATIVE

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Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted, two residents (R2-R3), three staff (S1-S3) and one witness (W1) denied that staff did not ensure that resident was advised of his personal rights. Based on records review, R1 has an Admission Agreement signed by the POA and it includes an attachment (#4), the Resident’s Personal Rights. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Allegation: Staff did not ensure that resident was provided with comfortable living accommodations.

It is alleged that Staff did not ensure that resident was provided with comfortable living accommodations. On 1/31/2023 between 11:05 am - 1:30 pm. LPA interviewed two out of nine residents (R2-R3) and three out of six staff (S1-S3). Since R1 has already moved out of the facility, LPA attempted to conduct a telephone interview but R1 refused the interview. On 2/6/2023, LPA conducted a telephone interview with one witness (W1). Based on interviews conducted, two residents (R2-R3), three staff (S1-S3) and one witness (W1) denied that staff did not ensure that resident was provided with comfortable living accommodations. Based on review of facility’s incident reports, there are no incidents where residents felt uncomfortable living in the facility. During the investigation, LPA observed the facility is a comfortable place to stay. Based on information gathered, there is no sufficient evidence to corroborate the allegation above.

Based on LPA’s observation, interviews conducted, and records review, the preponderance of evidence standard has not been met. 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.

Exit interview conducted and a copy of this report was provided to Caregiver, Mercedes Espino.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4