198320420-12-18-2023-11-AS-LVIS-CYMUXQ-20231218145843

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320420
Report Date: 12/18/2023
Date Signed: 12/18/2023 02:58:48 PM

Document Has Been Signed on 12/18/2023 02:58 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

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: 58	DATE:	12/18/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	House Manager Bella Lee		TIME COMPLETED:	04:15 PM

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On 12/18/23 Licensing Program Analysts (LPAs) Villegas,Gibbs, Dabuet and Iniguez conducted a pre-licensing evaluation for an RCFE (Residential Care Facility for the Elderly) Change of Ownership (CHOW). Today’s pre-licensing evaluation was conducted with House Manager Bella Lee.

The licensee has applied for a license to serve (111) age range 60 and over adults. The fire clearance is approved for (111) non-ambulatory. Waiver/Granted for Hospice Care for (25). Liability insurance is active.

LPA’s Villegas and Gibbs toured facility kitchen, dining Room, lounge areas, (72) Bedrooms, (77) bathrooms, basement, patios with shaded area and medication room.

LPA’s observed the following during this visit:

MEDICATIONS- There is a locked centralized storage area for Resident medications.

PHYSICAL PLANT- LPA observed Indoor and outdoor passageways, stairways, open areas, and other areas of potential hazard are free of obstructions. The facility temperature is between 68° degrees and 85° degrees.

BEDROOMS- No client bedroom is a passageway to another room, bath, or toilet. There is a bed for each client with a mattress, mattress pad, bedsprings. There is dresser and closet space for each client that includes at least two (2) drawers of dresser space per client.

BATHROOMS- There are plenty of toilets and washbasins for clients, family, and personnel. There are plenty of showers for clients, family, and personnel. The hot water temperature is between 105°-120° degrees Fahrenheit. Bathrooms are located inside client bedrooms and common areas.

FOOD SERVICE- The dining room is near the kitchen. The refrigerator and freezer are clean and have the capacity to store at least two (2) days of perishable foods. There is storage for a seven (7) day supply of

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 12/18/2023

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non-perishable food. There are enough tableware, tables, dishes, and utensils. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean.

RECORDS- There is confidential storage for personnel records at the facility. There is storage for Resident confidential information and records at the facility.

ADMINISTRATION- The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. A Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings.

ACTIVITIES- There is an outdoor activity space with a shaded area and furnished for outdoor use. There are at least 3 common areas available to clients for visitors. There are activities scheduled during the current month.

MISCELLANEOUS- There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries.

CORRECTIONS:

Smoke Detectors:

Smoke detectors in room #68 is not attached properly to the ceiling.

Physical Plant:
Room #31 exposed hazardous chemical spray
Room#11 obstruction bed blocking access to closet
Room #35 no hot water
Rooms #46, #83 and #84 window screens missing.
Rooms #13; #19, #44, 64, #66 and #80 cluttered
Room #29, #61 (being used as storage)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 12/18/2023

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Room #23, #36, #43, #46, #73 and #83 no linens
Room #23, #35, #7, #59 no furnishings
Room #39 no doorknob
Room #25 and #34 molds along the wall surfaces
Room #30 locked no key accessibility.

Pest Control: Roaches
Room #20, Room #21, Room #22, Room #24, Room #25, Room #35
Room #34, Room #35, Room #36, Room #85

Staff Records:
Fingerprint Clearances Exceptions (S2), (S3), (S7)
Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders (S3), (S4), (S5), (S7)
Criminal Statement (S3), (S7)
Health Screening (S3)
TB Test (S3)
Education Verification (S2), (S3), (S5), (S7)
Employee Rights (S4), (S7)
Missing File (S1), (S8)

Clients Records:
Consent Forms (R3), (R5)
Safeguard for Property/Valuables (R2), (R3), (R4)
Personal Rights (R3)

An exit interview was conducted, and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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