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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320420
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:42:33 PM

Document Has Been Signed on 01/16/2025 02:42 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 TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR/
DIRECTOR:		MIRAN BAEFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 111CENSUS: 49DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:46 AM
MET WITH:Eric Doan, TIME VISIT/
INSPECTION COMPLETED:
03:00 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
Licensing Program Analysts (LPA) Sparkle Day, Ernand Dabuet, Lizeth Villegas and Alfonso Iniguez conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one-year inspection. LPA met with Grace Hwang, Assistant Manager and the purpose of the visit was discussed. During this visit Erik Doan , Administrator arrived and assisted with the visit. The facility is licensed to serve 111 non- ambulatory residents age 60 and over . The facility has an approved hospice waiver for 25 residents. Current census is 49 The facility does not handle any of the residents’ money. Currently there are 4 residents receiving hospice services and 20 residents receiving home health services.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (72) resident bedrooms and (77) bathrooms. There is a administrative office, an activity area, dining area, kitchen, medication room, and an outside patio. LPA observed all walkways around the building to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises.

LPA inspected eleven (11) resident rooms with restrooms, including 1, 3, 4, 33, 46, 65,72, 74, 86, and 87 . LPA observed all rooms to be properly furnished with a bed, dresser, night stand, chair, and storage space for resident’s personal belongings. LPAs toured the dining room, kitchen, Activity room and medication room. The facility had required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew.. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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: 01/16/2025
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
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: 01/16/2025
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
Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPAs observed the following deficiencies and issued citations.

* Kitchen :Stoves in kitchen ( 2 isles not working) on 1 stove (oven not working)

* Dining room : 3 window panes cracked

* Back entrance door window pane cracked

*Physical Plant :Gate chained

*Personnel records

* Resident records

* personnel training

Exit interview conducted with Erik Doan, Administrator and Appeals Rights were explained. A copy of this report was provided

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/16/2025 02:42 PM - It Cannot Be Edited


Created By: Sparkle Day On 01/16/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 198320420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

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 LPAs identified two perimeter gate doors the northeast and the southwest gates had locks. Northeast gate has an egress device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2025
Plan of Correction
1
2
3
4
Licensee will adhire to tittle 22 regulations 87705(f)(1). Licensee will request a waiver to have locks and egrees on perimeter gates. Proof of correction must be sent to LPA Day via email before the POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/16/2025 02:42 PM - It Cannot Be Edited


Created By: Sparkle Day On 01/16/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 198320420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

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 LPAs identified room #48 is altered into a suite combine with room #72. Room #5 was converted into a laudry room with notification from CCLD or obtain local building permit and inspections which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
1
2
3
4
Licensee will adhire to title 22 regulations 87305(a). Licensee will notify CCLD and obtain building permit and local building inspection. Proof of correction will be submitted to LPA Day via email before POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in Based on records review LPA observed that the first aid trainings for staff 1-5 are expired which poses a health and safety concern for residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Licensee will adhire to title 22 regulations. Licensee/Administrator will review and ensure all staff have an active first aid certification and that all the first aid certifications are available and placed in each personnel file. Proof to be submitted to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/16/2025 02:42 PM - It Cannot Be Edited


Created By: Sparkle Day On 01/16/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 198320420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in Based on records review LPA did not observe required training certificates for staff 1-5 in personnel files, LPA only observed training schedules which poses a health and safety concern for residents in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Licensee will adhere to title 22 regulation87412(a)(12). Licensee/Administrator will review and ensure that all required trainings are completed by all staff and ensure all required training certifications for all employees are available and placed in each personnel file. Proof to be submitted to LPA by POC due date.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in not having SPV forms in file for the 5 resident records that were reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Licensee will adhere to title 22 regulation 87506(b)(16). Licensee/Administrator will review and ensure that all the SPV form are completed and filed on the residents files. Proof to be submitted to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 01/16/2025 02:42 PM - It Cannot Be Edited


Created By: Sparkle Day On 01/16/2025 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: HAYWORTH TERRACE
FACILITY NUMBER: 198320420

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(b)
Admission Agreements
(b) The licensee shall complete and maintain in the resident's file a Telecommunications Device Notification form (LIC 9158, 11/04) for each resident whose pre-admission appraisal or medical assessment indicates he/she is deaf, hearing-impaired, or otherwise disabled in accordance with Public Utilities Code sections 2881(a) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in not having the the telecommunications Device form on file for the 5 resident records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
1
2
3
4
Licensee will adhere to title 22 regulation 87507(b). Licensee/Administrator will review and ensure that the telecommunications Device form on file for the 5 resident records completed and file . Proof to be submitted to LPA by POC due date.
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:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
Page: 7 of 7