198320095-5-15-2024-11-AS-EMAZ-D7GUWV-20240724155722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320095
Report Date: 05/15/2024
Date Signed: 05/15/2024 10:57:46 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
11/03/2023 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231103143116

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:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Josephine Hauf/Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident fell and sustained a fracture due to staff neglect.
Facility staff did not provide an adequate quantity of food to resident.

INVESTIGATION FINDINGS:

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On 5/15/2024 LPA Alfonso Iniguez conducted a subsequent complaint visit to deliver findings about IB investigation. LPA Iniguez met with /Administrator and explained the purpose of this visit.

Investigation Consisted of: On 11/6/23 Licensing Program Analyst-LPA Alfonso Iniguez conducted a 24-hrs visit at the facility and gathered documentation from (R#1). LPA Iniguez gathered this information during the visit: Physician Orders for Life-Sustaining Treatment(POLST),Residential Appraisal, Physicians Report for Residential Care Facilities for the Elderly, paper sheet with information, discharge paper from Primrose Post Acute, Face sheet from Primrose Post Acute, Covid 19 test dated on 12/27/2022, Post acute PPD test result dated on 10/26/2022, Primrose Post Acute Order Summary Report from 12/27/2022, Discharge summary Primrose Post Acute 12/27/2022, (R#1) labs results done at TridentCare on 12/17/2022, Initial Assessment for Skilled Nursing Applicants,

See LIC 812 for more detatils...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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 5

Control Number 11-AS-20231103143116

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: 05/15/2024

NARRATIVE

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Investigation Revealed the Following:

Allegation: Resident fell and sustained a fracture due to staff neglect.

The details of the complaint alleged that a resident sustained fracture due to facility staff neglect.

On 11/6/23, complaint was accepted by IB for a full investigation and assigned to Special Investigator Lorraine Patterson. As part of the investigation, investigator Patterson obtained the (R#1)’s facility file, (R#1)’s medical records from Centinela Hospital, (R#1)’s interview, facility staff interview(S#1-S#2), witnesses’ interviews(W#1-W#2), facility administrator interview(A#1) and an Attempted contact with Reporting Party (RP)

Investigator Patterson conducted the following based on interviews.

On 12/11/23, Investigator Patterson spoke with Administrator (A#1), she stated that she does not suspect any neglect which led to (R#1)'s fall and subsequent fracture while in care. She maintained that during the time of their back-to-back falls on 05/2/23 and 05/03/23, they were medically and physically stable, and there was no change in their baseline that contributed to their fall. According to her, (R#1) was able to "push" themselves around and ambulate in their wheelchair while in care. (R#1) could call for help and make their needs known.

On 12/11/24, Investigator Patterson spoke with facility staff (S#1 and S#2), (2) out of (2) denied neglect/lack of supervision and care contributed to (R#1)’s falls that lead to (R#1)’ fractures.

On 12/11/24, Investigator Patterson spoke with residents in care (R#2 and R#3), (2) out of (2) state that they denied suspecting and or witnessing neglect from facility staff contributed to (R#1)’s falling sustaining a fracture or injury.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20231103143116

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: 05/15/2024

NARRATIVE

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On 1/17/2024 Investigator Patterson arrived unannounced at Hawthorne Convalescent Home Center to conduct an in-person interview with (R#1). (R#1) confirmed while they lived in care at Hawthorne Terrace Care Home, they sustained two falls (05/02/23; 5/03/23). (R#1) told investigator during their first fall they “slipped” while reaching for a paper because they had an appointment with the doctor that day and they needed to call transportation to pick them up. (R#1) stated that their first fall they injured their nose. (R#1) told investigator during his second fall that the “same” thing happened. (R#1) stated they “reached” for a potato chip on the floor and slipped out of his wheelchair. (R#1) told investigator during their second fall they sustained a broken hip. (R#1) denied neglect and or physical abuse that led/contributed to their fall sustaining a hip fracture. (R#1) told investigator after both falls 911 was called and they were taken right away to the hospital. (R#1) admitted facility staff instructed them to ask for help but they did not follow instructions.

The review of the Centinela Medical Center (#M000233890) dated 5/3/2023 revealed that (R#1) was admitted through the emergency room and the reason for the visit was right hip pain. The Chief Complaint stated that (R#1) had a mechanical fall from a wheelchair prior to their arrival while reaching for trash on the ground. (R#1) fell out of the wheelchair on their right side. (R#1) reached for something while in his wheelchair and fell. The Hospital Summary Report stated No suspected abuse. The Discharge Summary/Diagnosis stated: Neglect/Abuse Screening: None. Social Services Issues: None. Hip fracture, status post open reduction internal fixation. Discharge on 5/9/23.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20231103143116

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: 05/15/2024

NARRATIVE

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Allegation: Facility staff did not provide an adequate quantity of food to resident.

The details of the complaint alleged that facility staff did not provide an adequate quantity of food to residents.

During the physical tour of the facility's kitchen and food pantry, LPA observed an abundance of perishable and non-perishable food available for residents in care, as well as a 7-day food supply for emergencies.

During an interview with the administrator (A#1), she stated that the facility serves three meals per day to the residents: breakfast, lunch, and dinner, along with two snacks. Ambulatory residents are also able to help themselves to snacks in the kitchen. Additionally, when it comes to serving well-balanced and nutritious meals, (A#1) stated, "Yes, we serve good meals to residents. We provide protein, vegetables, and carbohydrates in every meal." Furthermore, (A#1) states that the facility has enough perishable and non-perishable food for residents in care, ensuring that residents do not go to bed hungry.

During interviews with residents (R#1-R#7), (5) out of (7) stated that the facility offers them three meals per day plus snacks. They mentioned that the facility provides well-balanced and nutritious meals consisting of protein, vegetables, and carbohydrates. Additionally, (5) out of (7) residents stated that the facility has enough food for them and the rest of the residents in care, and they have never gone to bed hungry.

During interviews with staff (S#1-S#2), both staff members stated that the facility offers three meals per day to residents in care: breakfast, lunch, and dinner, as well as snacks between meals. Additionally, both staff members stated that the residents receive well-balanced and nutritious meals that include protein, vegetables, and carbohydrates. They also mentioned that the facility has enough food available for all residents in care. Furthermore, both staff members stated that the residents do not go to bed hungry.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20231103143116

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: 05/15/2024

NARRATIVE

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During this investigation, LPA found did not find sufficient evidence to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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 Complaint Report was given to Josephine Hauf /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

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