198320420-1-3-2024-11-AS-LVIS-CZ5QWF-20240103113152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320420
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:31:56 AM

Document Has Been Signed on 01/03/2024 11:31 AM - 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:	01/03/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:31 AM
MET WITH:	House Manager Bella Lee		TIME COMPLETED:	01:15 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	On 01/03/2024 Licensing Program Analyst (LPA's) Villegas and Dabuet conducted a case management pre licensing visit to inspect corrections dated 12/18/23 during the pre licensing inspection. LPAs met with house manager Bella Lee and maintenance supervisor Juan Rossell as the purpose of the visit was explained. During the inspection visit LPA's reviewed the inspections for the following: Smoke Detectors: · Smoke detectors in room #68 is not attached properly to the ceiling. - corrected 01/03/24 Physical Plant: · Rooms #13; #19, #44, #64, #66 and #80 cluttered - corrected: 01/03/24 · Room #29, #61 (being used as storage) - corrected: 01/03/24 · Room #23, #36, #43, #46, #73 and #83 no linens - corrected: 01/03/24 · Room #23, #35, #7, #59 no furnishings - corrected: 01/03/24 · Room #30 locked no key accessibility.- corrected: 01/03/24 · Room #31 exposed hazardous chemical spray - corrected: 12/18/23 · Room#11 obstruction bed blocking access to closet - corrected: 12/18/23 · Room #35 no hot water faucet not operable - corrected: 12/27/23 · Rooms #46, #83 and #84 window screens missing. corrected: 12/28/23 · Room #39 no doorknob - corrected: 12/28/23 · Room #25 and #34 molds along the wall surfaces - corrected: 12/28/23 Pest Control: · Room #20 (roaches) - corrected: 12/28/23

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth Villegas	TELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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: 01/03/2024

NARRATIVE

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·Room #21 (roaches) - corrected: 12/28/23
· Room #22 (roaches) - corrected: 12/28/23
Room #24 (roaches) - corrected: 12/28/23
Pest Control
· Room #25 (roaches) - corrected: 12/28/23
· Room #34 (roaches) - corrected: 12/28/23
· Room #35 (roaches) - corrected: 12/28/23
· Room #36 (roaches) - corrected: 12/28/23
· Room #85 (roaches) - corrected: 12/28/23
Staff Records:
· Fingerprint Clearances Exceptions - (S2), (S3), (S7) - corrected: 01/03/24
· Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders - (S3), (S4), (S5), (S7) - corrected: 01/03/24
· Criminal Statement - (S3), (S7) - corrected: 01/03/24
· Health Screening - (S3) - corrected: 01/03/24
· TB Test - (S3) - corrected: 01/03/24
· Education Verification - (S2), (S3), (S5) and (S7) - corrected: 01/03/24
· Employee Rights - (S4), (S7) - corrected: 01/03/24
Resident Records:
· Consent Forms - (R3), (R5) - corrected: 01/03/24
· Safeguard for Property/Valuables - (R2), (R3), and (R4) - corrected 01/04/24
· Personal Rights (R3) - corrected: 01/03/24

An exit interview was conducted with House Manager Bella Lee, 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: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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