198320095-10-10-2024-11-AS-SLEO-D9WQY9-20241010123445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320095
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:34:56 PM

Document Has Been Signed on 10/10/2024 12:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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:	10/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator - Zuo Fen Hauf		TIME COMPLETED:	01:00 PM

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	On 10/10/2024 at around 8:30 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator Zuo Fen Hauf. LPA explained the purpose of the visit and was accompanied by a staff inside and outside the facility during this inspection. This facility is licensed to serve 14 adults ages 60 and above, of which 6 maybe non-ambulatory, and 6 maybe on hospice. A total of 10 residents are currently residing in this facility. The Annual Licensing Fees are current. The facility is a one-story house located on a main street. The home consists of 7 resident bedrooms, 1 staff bedroom, 3 full bathrooms, 1 toilet room, 1 entry/living room, 1 kitchen, 1 dining/living room, 1 laundry room, 1 attached garage, 1 backyard area with shaded seating.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last earthquake drill was conducted on 09/12/2024. First aid kit is fully stocked with manual. The facility has a fire control panel, pull fire alarms and sprinklers. The fire system is connected to their local Fire Department. The facility pays a monthly payment to the All-American Fire System Inc. There are several fire extinguishers on the premises, and they were last serviced on 04/30/2024. There are two landline telephones; both telephones are in each living room. There is a videoconferencing device dedicated for client use in the area.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

NARRATIVE

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7 out of 7 residents’ bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. LPA observed that closet doors were in disrepair in rooms 2, 3, and 4. LPA observed that 1 bathroom sink was in disrepair. Bathroom toilets and grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products as nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
5 resident records were reviewed and, 4 out of 5 resident records had required documentation and 1 out 5 resident records did not have consent forms. Administrator agrees to document residents consent forms.

Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding facility being in disrepair.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/10/2024 12:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAWTHORNE TERRACE CARE HOME, LLC	FACILITY NUMBER: 198320095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having rooms 2, 3, and 4 closet doors in disrepair and having 1 bathroom sink in disrepair, which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Licensee agrees to fix closet doors in rooms 2, 3 and 4. Licensee agrees to fix bathroom sink. Licensee will take videos and send them as proof of correction to Socorro.Leandro@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro Leandro	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024

LIC809 (FAS) - (06/04)

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