198320420-12-19-2024-11-AS-RORN-DD6V5H-20250122150800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:37:00 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
12/16/2024 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20241216104340

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	198320420
ADMINISTRATOR:	PARK, MAN		FACILITY TYPE:	740
ADDRESS:	325 N HAYWORTH AVE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 49	DATE:	12/19/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Grace Hwang, Assistant Manager		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff did not administer resident's medications as prescribed.
Staff force resident to bed.

INVESTIGATION FINDINGS:

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On 12/19/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Assistant Manager, Grace Hwang and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:

On 12/19/24 LPA Felisa Shirley requested, received and reviewed copies of the following records: Staff Roster and Resident Rosters. LPA Shirley requested the following records for R-1: Medication Administration Log (MAR) and physician’s report. LPA also interviewed staff 1 thru staff 5 and resident 1 thru resident 5.

The investigation revealed the following:

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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-20241216104340

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: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 12/19/2024

NARRATIVE

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Allegation: Staff did not safeguard resident's personal belongings.

It was reported that R-1 is missing all of their clothing. LPA Shirley conducted a search of residents clothing and did not find the 4 articles of clothing that resident states was missing. LPA observed the clothing in R-1’s closet and counted the overcoats mentioned in complaint and other articles of clothing and women’s outfits, which LPA described to the resident. LPA Shirley toured the facility and went to 7 different storage rooms and did not find the clothing.

LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff safeguard residents personal belongings. Of those interviewed, 5 out of 5 staff answered yes. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, does staff safeguard all of your belongings. Of those interviewed, 4 out of 5 answered yes, 1 answered no. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not safeguard resident’s personal belongings,” therefore the allegation is unsubstantiated.

Allegation: Staff did not administer resident's medications as prescribed.

It was reported that R-1 has not been administered their medications. LPA requested and reviewed R-1’s Medication administration Record (MAR) and observed that all prescribed medications were administered as prescribed since day of admission. R-1 stated that staff gives her the medications in a little plastic bag. Staff watches her take the
Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20241216104340

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: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 12/19/2024

NARRATIVE

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medication and then leaves. R-1 states that staff does not tell her what medication she is taking.

LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, does staff administer resident’s medications as prescribed. Of those interviewed, 4 out of 5 staff answered yes and 1 answered I don’t know. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, do you receive your medications as prescribed. Of those interviewed, 5 out of 5 answered yes. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not administer resident’s medication as prescribed,” therefore the allegation is unsubstantiated.

Allegation: Staff force resident to bed.

It was reported that R-1 was made to go to bed when they were not ready to go to sleep. R-1 stated that staff pushed her shoulders down towards the bed and she kept telling them no. During interviews, S-5 stated there is no bedtime, but the residents are observed by caregivers as it gets closer to 10 to see if they are sleeping or looking tired and are encouraged to return to their rooms so as to not be roaming around the facility.

LPA Shirley interviewed staff-1 thru staff-5 (S-1 thru S-5). LPA asked, if there is an assigned bedtime for residents. Of those interviewed, 3 out of 5 staff answered no, 1

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20241216104340

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: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 12/19/2024

NARRATIVE

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stated 7pm and 1 answered I don’t know. LPA interviewed Resident-1 thru Resident-5 (R-1 thru R-5). LPA asked residents, are you forced to go to bed when you are not ready. Of those interviewed, 4 out of 5 answered no, 1 stated, somedays they just push my shoulders and say go to bed. Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff force residents to bed,” therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of the LIC 9099 report was provided to the Assistant Manager, Grace Hwang.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC9099 (FAS) - (06/04)

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