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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 03/19/2025
Date Signed: 03/20/2025 02:36:12 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
03/07/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250307091106
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: 51DATE:
03/19/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Grace HwangTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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The resident's medical and dental needs are not being met.
Staff are not safeguarding resident’s personal belongings.
INVESTIGATION FINDINGS:
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On March 19, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Grace Hwang, the assistant administrator, greeted the (LPA). (LPA) explained the purpose of this visit was to investigate the allegations mentioned above.

The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #2 (S1-S2), resident members #1 to -#5 (R1-R5), and witnesses #1 to #2 (W1-W2). The Department reviewed several documents, including the Facility Staff Roster (dated 03/13/25), the Resident Roster (dated 03/13/25), Resident #1 (R1)'s Residential Care Admission Agreement (dated 03/22/2020), Physicians Report LIC 602A (dated 03/22/23), Appraisal/Needs and Services Plan LIC 625 (dated 03/22/20, and 03/10/23), 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: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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
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
03/07/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250307091106

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: 51DATE:
03/19/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Grace HwangTIME COMPLETED:
01:59 PM
ALLEGATION(S):
1
2
3
4
5
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9
Staff are not allowing resident to leave the facility.
INVESTIGATION FINDINGS:
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On March 19, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Grace Hwang, the assistant administrator, greeted the (LPA). (LPA) explained the purpose of this visit was to investigate the allegation mentioned above.

The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with staff members #1 to #2 (S1-S2), resident members #1 to -#5 (R1-R5), and witnesses #1 to #2 (W1-W2). The Department reviewed several documents, including the Facility Staff Roster (dated 03/13/25), the Resident Roster (dated 03/13/25), Resident #1 (R1)'s Residential Care Admission Agreement (dated 03/22/2020), Physicians Report LIC 602A (dated 03/22/23), Appraisal/Needs and Services Plan LIC 625 (dated 03/22/20, and 03/10/23), 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: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff are not allowing resident to leave the facility.

The complaint details alleged that the facility staff were not allowing Resident #1 (R1) to leave the facility. It was reported that it is customary for (R1) to participate in social activities outside the facility, but on March 6, 2025, (R1) was not permitted to leave.

On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the (2) two staff members denied the claim. (S1) explained that (R1) does not have a conservator, power of attorney, or public guardian representing them. (R1) frequently receives visits from close personal friends at the facility. However, on March 6, 2025, (R1) had a visitor whom (S1) did not recognize. (S1) asked the visitor questions, but the individual refused to provide identification and did not want to sign the visitor log or follow the facility's proper guidelines.

(S1-S2) reported that visitation with residents is encouraged at any time, but visitors are expected to respect the other residents, staff, and guests on the facility's premises. (S1) described the visitor as uncooperative, so authorization for the visitor to leave the facility with (R1) was denied. (S1) emphasized that the facility is responsible for ensuring the well-being and safety of residents both inside and outside the facility and returning safely.

On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed to have no issues or concerns with family and friends visits at the facility. Although they know they have the right to leave the facility, most visits have been only inside the facility.

On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified Witness #1 and Witness #2 (W1-W2). Two (2) out of the two (2) witnesses who claimed to have never had any issues with their visits to the facility. (W1-W2) were identified as guests of (R1) who followed the rules, signed the visitor's log, and announced the purpose of their visits.


The Department reviewed the Residential Care Admission Agreement (dated March 22, 2020) and revealed a signed agreement by (R1) on page 11 under the section Visitation and Communication, the guidelines for visitation with residents.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
NARRATIVE
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In addition, a review of (R1's) Identification and Emergency Information LIC 601 (dated March 22, 2020) showed that (R1) did not have an authorized guardian, conservator, or power of attorney assigned. After reviewing the facility's visitor log from January 1, 2025, to March 2025, it was confirmed that (R1) 's guest did not sign in during the visit on March 6, 2025, supporting (S1) 's statement.

Resident #1 (R1) was interviewed on March 13, 2025, with the help of an interpreter. However, (R1) was unable to participate in the interview due to (R1)'s health condition.

Based on the gathered information, insufficient evidence supports the stated allegation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated.


An exit interview was conducted with Grace Hwang, and copies of the reports were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #2: The resident's medical and dental needs are not being met.

The complaint details allege Resident #1 (R1)’s medical and dental needs are unmet. It was reported that (R1) has been at the facility for several years and has not received proper routine medical and dental care. No further information has been provided relating to this allegation.

On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the two (2) staff members claimed that (R1) has received routine medical care. (R1) was admitted at Hayworth on March 22, 2020, and had several changes with the primary physicians throughout the years. (S1) stated (R1)’s medical needs are serviced by an internal primary physician who visits the physical facility monthly. However, (R1) has not received dental care since (R1)’s admission. (S2) stated that visits to medical physicians and psychiatric services are monthly. The podiatry services are every two months, and vision care services are every six months.

On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed to receive medical and dental care with the internal primary physician regularly and did not present any concerns or issues with the care provided.

On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified as Witness #1 and Witness #2 (W1-W2), Two (2) out of the (2) witnesses who echoed the same concerns that (R1) doesn’t seem to be getting routine medical needs or assistance. (W1-W2) during their visitations, (R1) has never been observed being medically assessed by any medical professional at the facility.

The Department audited (R1)’s service files and discovered (R1) had only one Physicians Report LIC 602A (dated March 03, 2023), two Appraisal/Needs and Services Plan LIC 625 (dated March 22, 2020 and March 10, 2023). Despite facility staff's claims that (R1) is receiving routine medical care services, no current medical assessments or records of medical or dental care are included in (R1)’s service file. The Department attempted to verify (R1)’s medical care by contacting (R1)'s current primary physician, but calls were not returned.


Based on the gathered information, sufficient evidence supports the stated allegation.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
NARRATIVE
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Allegation #3: Staff are not safeguarding resident’s personal belongings.

The complaint details that staff are failing to safeguard the personal property of Resident #1 (R1). It has been reported that (R1’s) belongings, including dentures, socks, and fresh flowers, are frequently missing, and theft of items is common at this facility. Furthermore, the staff has not tried to assist (R1) in replacing these lost items.

On March 13, 2025, between 9:15 AM and 10:00 AM, the Department interviewed staff members, identified as Staff #1 and Staff #2 (S1-S2). Two (2) out of the (2) staff members claimed that (R1) lost some property valuables in the past. (S1) stated that (R1) routinely will misplace or lose (R1)'s dentures. (S1) said the facility does its best to safeguard the resident's property valuables by doing routine room checks through supervision.

On March 13, 2025, between 10:30 AM and 02:15 PM, the Department interviewed resident members identified as Resident #1 through Resident #5. Four (4) out of the five (5) residents claimed they had all been victims of theft at the facility. Individuals R2-R5 reported that money, hygiene products, clothing, and small electronics were stolen or lost.

On March 13, 2025, between 1:30 PM and 02:45 PM, the Department interviewed witness members and identified Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witnesses who claimed to have provided (R1) with blankets, hygiene supplies, and clothing and have never seen again. No explanation is provided for the missing or lost items.

The Department reviewed various documents related to (R1), including Physicians Report LIC 602A (dated March 03, 2023), two Appraisal/Needs and Services Plan LIC 625 (dated March 22, 2020, and March 10, 2023), Identification and Emergency Information LIC 601 (dated March 22, 2020), Face Sheet (dated March 22, 2020), Medication Administration Record (dated March 01, 2025, through March 31, 2025), Residential Care Admission Agreement (dated March 22, 2020), Personal Right LIC 613C (dated March 22, 2020), Consent for Emergency Medical Treatment (dated March 22, 2020), it revealed that (R1) did not have the required document, Resident Personal Property & Valuables LIC 621 on record.

Resident #1 (R1) was interviewed on March 13, 2025, with the help of an interpreter. However, (R1) was unable to participate in the interview due to (R1)'s health condition.


Based on the gathered information, sufficient evidence supports the stated allegation.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2025
Section Cited
CCR
87217(a)(1)
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(a) A plan for incidental medical and dental care shall... encourage routine medical and dental care and provide for assistance in obtaining such care... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Licensee will adhere to Title 22 87217 and ensure that (R1) will receive a current medical assessment LIC 602A and dental care by POC due date. LIcensee will send proof of correction to LPA Dabuet at ernand.dabuet@dss.ca.gov.
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This requirement is not met as evidence:
Based on interviews and record reviews, the licensee did not comply with the section. (S1) admitted (R1) has been neglected with dental care and medical care needs were being provided routinely but failed to provide medical records as evidence that medical care are being met. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
04/09/2025
Section Cited
CCR
87217(b)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents' ..., personal property and valuables which have been entrusted to the licensee or facility staff.
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Licensee will submit a plan to the LPA explaining how the facility will safeguard resident's personal property and send an completed LIC 621 to LPA Dabuet by POC due date at ernand.dabuet@dss.ca.gov
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This requirement was not met as evidence.
Based on interviews and record reviews, the licensee did not comply with the section. Interviews with R2-R5 indicated loss of property and facility did not have LIC 621 for R1. This violation which poses/posed a potential health, safety or personal rights risk to persons 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: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20250307091106
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: 03/19/2025
NARRATIVE
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Based on observations, interviews, and record reviews, the preponderance of evidence standard for NEGLECT and LACK OF CARE AND SUPERVISION" has been met. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted with Grace Hwang, the assistant administrator. During the interview, a hard copy of the report and information on appeal rights were provided.

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

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8