198320095-3-14-2024-11-AS-MVAO-D3QSPB-20240326140253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:33:38 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
01/09/2024 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20240109150139

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:	03/14/2024
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Mercedes Espino		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not dispense prescribed medication to resident.
Staff refused to return resident’s personal belongings.

INVESTIGATION FINDINGS:

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On 03/14/24 LPA Villegas conducted a subsequent complaint visit regarding the allegations above. LPA met with Mercedes Espino as the purpose of today’s visit was explained.

The investigation consisted of the following: On 01/17/24 LPA interviewed Administrator (A1), staff #1-2 (S1-S2),resident #2-6 (R2-R6) and Witness #1(W1). On 01/17/24 LPA obtained copies of the following; Resident and staff roster, training log for S1, copy of physician license for A1 and the following for resident #1 (R1); Identification and emergency Info form, admission agreement, resident appraisal, physicians report, resident BP/Glucose checks, MAR for October-December 2023, Centrally stored medication and destruction record, admission record from prior facility.

The investigation revealed the following:
Allegation:Staff did not dispense prescribed medication to resident.
It is being alleged R1 had not received prescribed insulin since R1 started living at the facility.

Unsubstantiated

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: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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-20240109150139

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: 03/14/2024

NARRATIVE

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On 01/17/24 LPA interviewed A1 regarding the allegation above, A1 denied the allegation above. Per A1, insulin was administered daily and would only be withheld if blood sugar was too high, or if R1 would refuse. A1 continued to report that prior to R1 admitting to Hawthorne Terrace care home, LLC it was advised that prior placement educate R1 on how to check blood sugar; however when R1 arrived to Hawthorne Terrace care home, LLC R1 was unable to do. On 01/17/24 LPA interviewed S1-S2 regarding the allegation above, 2 of 2 staff interviewed denied the allegation above. On 01/17/24 LPA interviewed W1 regarding the allegation above, W1 reported R1 was provided with insulin upon discharge however, W1 could not recall if R1 was taught on how to check blood sugar or administer own insulin. W1 also reported W1 could not remember if R1 was medication complaint while in care. On 01/17/24 LPA interviewed R2-R6 regarding the allegation above, 5 of 5 residents interviewed denied the allegation above and reported receiving medication daily. On 01/17/24 LPA conducted review of MAR and did not observe any discrepancies, BP/Glucose checks as well as medication refusals were documented.

Allegation: Staff refused to return resident’s personal belongings.
It is being alleged facility staff is refusing to return R1’s clothing. On 01/17/24 LPA interviewed A1 regarding the allegation above, A1 denied the allegation. Per A1, R1's belongings have been packed and are ready to be picked up however, there has been no communication from R1's family on when the belongings will be picked up from the facility. On 01/17/24 LPA interviewed S1-S2 regarding the allegation above, 2 of 2 staff interviewed denied the allegation above and stated R1's belongings are packed in 2 boxes and have been ready for pick up. On 01/17/24 LPA interviewed R2-R6 regarding the allegation above, 5 of 5 residents interviewed denied the allegation above and reported that no personal belongings have gone missing while in care. On 01/17/24 LPA conducted a tour of the facility and observed R1's belongings to be packed in boxes and stored in the facilities storage space.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted with Mercedes Espino, and a 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: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC9099 (FAS) - (06/04)

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