<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:17:23 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
05/14/2025 and conducted by Evaluator Elvira Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250514114905
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:MIRAN BAEFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 48DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Terri HanTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek timely medical attention for resident.
Staff mismanaged residents’ medication.
Staff dispensed medication not prescribed to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/04/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to deliver amended report for the allegations mentioned above. LPA met with Admission Assistant, Terri Han, and the purpose of the visit was explained. LPA was granted entrance to the facility.

**This report supersedes the report created and delivered on 07/02/25. This report is to clarify findings.

On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility.


Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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-20250514114905
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: 09/04/2025
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
26
27
28
29
30
31
32
The investigation consisted of the following:

On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #2-#6 (R2-R6) and was unable to interview R1. Additionally, LPA and Aldo Apostol conducted a tour of the facility.

The investigation revealed the following:

Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it.

On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 6 residents stated that staff do seek medical attention for residents when they need it. 5 out of 6 residents stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 6 residents stated that they are satisfied with the services being provided to them.

A review of records revealed that R1s family member emailed Dr. Whiteman on 11/01/23 letting the doctor know that R1 had swelling in their right leg, below the knee, for over two months.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250514114905
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: 09/04/2025
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
26
27
28
29
30
31
32
Email also stated that R1 had a corn on their right pinky toe, and that R1 reported a 7 out of 10 on the pain scale. On 04/05/24, R1’s family member emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that R1’s family member took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that R1’s family member took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that R1’s family member took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that R1’s family member took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that R1’s family member took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension.

Although records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medical Network for health-related issues. There is not enough evidence to support the allegation that the facility did not seek timely medical attention for the resident.

Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250514114905
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: 09/04/2025
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
26
27
28
29
30
31
32
On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 6 residents stated that staff has not mismanaged their medication. 5 out of 6 residents stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 6 residents stated that staff administer their medication on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them.

On 05/19/25, LPA Gonzalez reviewed the Medication Administration Record (MAR) (dated: 03/01/25-03/31/25) for R1 and did not observe any discrepancies. Facility did not provide LPA with MAR’s for previous months for review.

Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party.

On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R2-R6. Based on interviews conducted, 5 out of 6 residents stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 6 residents interviewed stated that staff administer their medication to them on time and as prescribed by their physician. 5 out of 6 residents stated that they are satisfied with the services being provided to them.

On 05/19/25, LPA Gonzalez reviewed the Medication Administration Record (MAR) (dated: 03/01/25-03/31/25) for R1 and did not observe any discrepancies. LPA was not able to obtain MAR’s for previous months for review.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250514114905
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: 09/04/2025
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
26
27
28
29
30
31
32
Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and a copy of this report along with appeal rights was provided to Terry Han, Admission Assistant.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5