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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 04/30/2025
Date Signed: 04/30/2025 11:00:29 AM

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
03/27/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250327082253
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: 50DATE:
04/30/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Grace Huang, Assistant AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not allow resident to have a visitor
Staff are preventing resident from moving out of facility
INVESTIGATION FINDINGS:
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On 4/30/25, Licensing Program Analyst (LPA) Felisa Shirley conducted a subsequent unannounced visit to this facility. LPA was met by Assistant Manager, Grace Hwang and explained the purpose of the visit is to investigate the allegations mentioned above and deliver findings. LPA was granted access to the facility.
The investigation consisted of the following:

On 04/3/25 LPA Felisa Shirley requested, received and reviewed copies of the following records: Staff Roster, Resident Roster, March Visitor Log, and Rent Payment for Resident. LPA Felisa Shirley interviewed facility Assistant Manager, reviewed facility records and interviewed Staff 1 through Staff 4 and Resident 2 through Resident 5. R-1 was not available due to diagnosis.

The investigation revealed the following:

Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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 4
Control Number 11-AS-20250327082253
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: 04/30/2025
NARRATIVE
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Allegation: Staff did not allow resident to have a visitor

On 4/3/25, LPA Shirley reviewed facility records that does not show a visitor for R1 on 3/26/25. Per communication with W1, they went to Hayworth Terrace for an assessment and requested to be taken to R1’s room but S1 hesitated and stated that family needs to contact staff first if they want to move R1 out as R1 had payment delinquency. W1 wanted to avoid confrontation with S1, so they left. Per interview on 4/3/25, S1 denied entrance of W1 who was there to conduct an assessment of R1 for relocation due to outstanding rent payment. Per S1, W1 left and said that they would return.

LPA Shirley interviewed staff-1 thru staff-4 (S-1 thru S-4). LPA asked, if staff allow residents to have visitors. Of those interviewed, 4 out of 4 staff answered yes. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked residents, if staff allows them to have visitors. Of those interviewed, 4 out of 4 answered yes.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on records reviewed and interviews conducted the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be substantiated.

Allegation: Staff are preventing resident from moving out of a facility



The details of the complaint allege that facility staff is not allowing resident to move due to an outstanding balance. On 4/3/25, LPA Shirley reviewed Rent Payment History record

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250327082253
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: 04/30/2025
NARRATIVE
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provided by facility staff. Per record reviewed, R1 owes this facility outstanding rent. Per interview with S1, S1 told W1 that R1 has a payment delinquency and then denied entrance to conduct an assessment. Per communication with W1, S1 stated the family needs to contact staff first if they want to move R1 out.

LPA Shirley interviewed staff-1 thru staff-4 (S-1 thru S-4). LPA asked, if staff prevented residents from moving out of the facility. Of those interviewed, 4 out of 4 denied the allegation. LPA interviewed Resident-2 thru Resident-5 (R-2 thru R-5). LPA asked residents, if staff prevented them from moving from this facility. Of those interviewed, 2 out of 4 answered no and 2 residents did not know.

During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on records reviewed and interviews conducted the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be substantiated.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.



An exit interview was conducted, and a copy of this report was provided to Assistant Administrator Grace Huang.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250327082253
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: 04/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2025
Section Cited
CCR
87468.1(a)(11)
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87468.1 Personal Rights of Residents in All Facilities


(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.


This requirement is not as evidenced by:
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Administrators shall review regulation and train all staff on accepting visitors for all residents. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 5/14/25, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.
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Based on interview, S1 admitted denying W1 entrance to facility. This poses a potential personal rights violation to persons in care.
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Type B
05/14/2025
Section Cited
CCR
87468.2(a)(2)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.

This requirement is not as evidenced by:
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Administrators shall review regulation and train all staff. Please provide copy of In-Service Training signed by all staff and submit to CCLD by POC due date of 5/14/25, Attn: LPA Felisa Shirley at felisa.shirley @dss.ca.gov or fax to 424-544-1016.
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Based on interview, S1 divulged confidential information and did not agree to release R1. This poses a potential personal rights violation 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4