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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 11/08/2025
Date Signed: 11/08/2025 11:01:59 PM

Substantiated


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
06/24/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250624090908
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 61DATE:
11/08/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Hee Kyung ParkTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident leading to hospitalization.
Staff refused to call 9-1-1 for resident.
INVESTIGATION FINDINGS:
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On November 08, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Licensed Vocational Nurse, Hee Kyung Park, greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegations mentioned above.

The investigation consisted of the following: On June 25, 2025, the department conducted an initial visit and met with House Manager Miran Bae (S2). A subsequent visit was completed by the department on November 08, 2025. During the initial visit, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Resident Roster (dated: 06/25/25), Staff Roster (dated: 06/25/25), (R1's) Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25), Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25) and other pertinent records associated with this complaint.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
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 8
Control Number 11-AS-20250624090908
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: 11/08/2025
NARRATIVE
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This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris.

As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2).

INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #1: Staff did not seek timely medical attention for resident leading to hospitalization.


ALLEGATION #2: Staff refused to call 911 for resident.

It has been alleged that Resident #1 (R1) did not receive timely medical attention, which ultimately resulted in hospitalization. Additionally, staff allegedly refused to call 911 when needed. Between June 1, 2025, and June 3, 2025, it was noted that (R1) was in pain and was being treated with pain patches and pain pills. During this time, the facility was contacted several times, but no one was available to respond to the calls.

On June 14, 2025, a request was made for (R1) to receive hospital treatment for the right arm, but staff again refused to call 911. The facility maintains that it is not responsible for transporting the resident to the hospital, even with a doctor's correspondence for medical treatment in place. Staff indicated they needed a physician's referral before contacting 911 for hospitalization, and it was clear they were unwilling to call for emergency assistance.

On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and informed staff about the fall. (R1) advised staff (R1) was in pain “every day”, and the staff gave (R1) “pain pill”, and place “pain patch” on (R1’s) arm. (R1) added that “No one thought I was hurt”.

(Evaluation Report continue LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20250624090908
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: 11/08/2025
NARRATIVE
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On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) all denied both allegations. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it.

However, (3) out of the (4) staff members were aware or made aware of (R1) being provided with pain pills and pain patches for (R1’s) shoulder pain for several days less or a week. (S1-S4) claimed that (R1’s) pain to the back and right shoulder was due to being “elderly” and had carried a “heavy bag” so complaining was not unusual. (S1-S3) claimed to have no documentation of over-the-counter medications or incidents of falls for (R1).

Regarding the procedure for contacting emergency services, (S1) stated that Besht Wellness Center has instructed its staff to call 911 and arrange for Non-Emergency Medical Transportation (NEMT) when necessary. According to (S2), policy dictates that if a resident falls and sustains an injury, 911 should be called or the resident should be taken to see a doctor.

On July 07, 2025, at 11:00 AM, the Department interviewed Witness #1 (W1). According to (W1), on May 22, 2025, (W1) was informed about (R1's) bed fall, and the facility cannot contact 911 without a doctor's approval.

On July 31, 2025, at 03:00 PM, the Department interviewed Witness #2 (W2). (W2) reported that an X-ray order was sent to Besht Wellness Center on May 2, 2025, by (S4). (R1) had been experiencing moderate pain for seven days. The X-rays were performed on May 8, 2025. (W2) confirmed that (R1's) shoulder issue was classified as “chronic” because treatment did not start until May 14, 2025, despite the pain being reported on May 2, 2025. This delay contributed to the chronic classification.

On July 30, 2025, and September 17, 2025, between 01:00 PM and 04:00 PM resident members interviewed identified as Resident #2 to Resident #5 (R2-R5). Four (4) of the (4) claimed they were unable to support the staff's refusal-to-contact-911 allegation. (R2-R5) were unaware of any harm and denied knowing about the staff's refusal to provide timely medical assistance with 911.

The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25), which indicated that attempts to reach the facility regarding (R1’s) fracture were unsuccessful. “Attempted to contact the facility multiple times using all phone numbers on file; no answer and disconnected.” Transfer orders were sent to the facility by fax on May 13, 2025, due to a lack of response.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20250624090908
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: 11/08/2025
NARRATIVE
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 Besht Wellness Center sent an email to the facility stating (R1’s) X-Ray shows a fracture-dislocation of the proximal humerus and advised (R1) to be transported to the emergency department for treatment via (NEMT). Further review of the Hollywood Presbyterian Medical Center medical records (dated 07/08/25) reported an inability to reach the facility, as noted in the documents, “Multiple attempts were made to reach staff at the assisted living facility with no success.” Medical records revealed (R1) notable for an obvious deformity,” and “it is possible that since the shoulder might have been out for up to a week, reduction is no longer possible.”

The Department reviewed the California Department of Social Services Provider Information Notice (PIN) 25-06-ASC, dated June 24, 2025. The notice states that it is best practice for the licensee to immediately call 9-1-1 if a resident is experiencing serious injuries, such as “obvious broken bones”, or if they have “falls with complaint of pain or loss of range of motion.”

Based on the gathered information, the facility showed no urgency in following up on June 6, 2025, X-ray results, despite staff knowing that (R1) was in "severe pain," according to (S4) and medical records. Hollywood Presbyterian Medical Center indicated (R1's) fracture required surgery, likely due to the delayed medical attention. The staff noted that (R1) had significant pain for a week, relying on over-the-counter medications for relief. However, there was a lack of communication about arranging Non-Emergency Medical Transportation (NEMT) to meet (R1's) needs.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

*Immediate Civil Penalty issued*

An exit interview was conducted with , and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
06/24/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250624090908

FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: DATE:
11/08/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Hee Kyung ParkTIME COMPLETED:
03:25 PM
ALLEGATION(S):
1
2
3
4
5
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The resident suffered a dislocated shoulder due to staff negligence.
INVESTIGATION FINDINGS:
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On November 08, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Licensed Vocational Nurse, Hee Kyung Park, greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegations mentioned above.

The investigation consisted of the following: On June 25, 2025, the department conducted an initial visit and met with House Manager Miran Bae (S2). A subsequent visit was completed by the department on November 08, 2025. During the initial visit, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Resident Roster (dated: 06/25/25), Staff Roster (dated: 06/25/25), (R1's) Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25), Besht Wellness Center (dated 06/13/25) where (R1) denied any recent falls but per Hollywood Presbyterian Medical Records (dated 07/08/25) and other pertinent records associated with this complaint.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20250624090908
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: 11/08/2025
NARRATIVE
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This complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Christine Ferris.

As part of the investigation, Investigator Ferris subpoenaed medical progress notes from Besht Wellness Center (dated 06/13/25), Hollywood Presbyterian Medical Records (dated 07/08/25), Home Health Care Medical Records (dated 01/24/25), Behst Wellness Center Medical Records (dated 06/01/25) Besht Wellness Center (dated 07/01/25) Besht Wellness Progress Notes (dated 05/14/25), ALSO Home Health Care, Inc (dated 01/09/25), Professional Care Home Health, Inc (dated 05/10/25) and Besht Wellness Center Progress Notes (dated 06/15/25). Furthermore, the investigator conducted interviews with Staff #1- #4(S1-S4), Witness #1-W#2 (W1-W2), and Resident #1-#2 (R1-R2).

INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #3: The resident suffered a dislocated shoulder due to staff negligence.

It is alleged that Resident #1 (R1) suffered a dislocated shoulder due to staff negligence. On May 22, 2025, (R1) was observed with their right arm hanging limp and dragging, and (R1) complained of pain. When this was reported to the facility staff who stated that the hanging arm was due to old age and was not a concern. Additionally, it was noted that facility management was unable to provide clarification on the matter during multiple inquiries. No further details about this incident were provided.

On July 09, 2025, at 11:30 AM, the Department interviewed Resident #1 (R1). (R1) reported to have been living at Hayworth Terrace for about six months (date of placement 12/18/24). (R1) expressed (R1) fell out of bed and injured the shoulder. (R1) did not call for assistance prior to or after the fall and is able to lift self from the floor, which (R1) did after the fall. The facility had no documentation of (R1) notifying them of a fall and denied any know of a fall.

On July 09, 2025, and August 11, 2025, between 11:30 AM and 02:00PM, staff members interviewed identified as Staff #1 through Staff #4 (S1-S4) who are unable to support this claim. (S1-S4) stated they were unaware of any fall involving (R1) and that (R1) never notified them about it. Additionally, there was no documentation from the facility indicating any notification from (R1) regarding the fall.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20250624090908
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: 11/08/2025
NARRATIVE
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On July 07, 2025, at 11:00 AM, the Department interviewed witness member identified as Witness #1 (W1). (W1) was not aware of (R1's) fall or fractured shoulder until (R1) disclosed the injury on May 22, 2025. During this conversation, (R1) mentioned that (R1) had fallen out of bed and was experiencing pain in the right shoulder. According to (W1), no one at the facility had notified (W1) about the fall.

The Department reviewed medical progress notes from Besht Wellness Center (dated 06/13/25) where (R1) denied any recent falls but per Hollywood Presbyterian Medical Records (dated 07/08/25) (R1) reported (R1) fell out of bed but did not not know when it occurred. Further review of the Physicians Report LIC 602A (dated12/23/24), and Home Health Care Medical Records (dated 01/24/25).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with the Licensed Vocational Nurse, Hee Kyung Park, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20250624090908
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2025
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.
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Licensee/Administrator will review Title 22 87466 Observation of Resident. Licensee will provide staff with training on observation of the residents. Licensee will provide copies of training materials and sign-in sheet to CCL by POC 11/10/25 and submit to ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by: Based on interviews, observation, and record reviews, the Licensee was aware of (R1's) the Licensee knew R1 had significant pain for a week but didn't seek medical attention, leading to hospitalization and surgery for fracture. This violation poses an immediate health and safety risk to residents in care.
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*Immediate Civil Penalty*
Type B
11/22/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...
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Licensee/Administrator must submit a written statement outlining staff protocols for addressing injured residents in emergencies and non-emergencies, including the provision of medical attention. Review PIN 25-06 ASC and 87465 Title 22 regulations and submit the protocol by 11/22/25 to ernand.dabuet@dss.ca.gov.
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This requirement is not met as evidenced by: Based on interviews, observation, and record reviews,(R1) experienced significant pain for a week, but there was inadequate communication about arranging Non-Emergency Medical Transportation (NEMT). This violation poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8