198320420-1-31-2024-11-AS-EMAZ-D2PTXE-20240222140700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:57:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240126143235

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:	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Bella Lee		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not properly secure the residents medications
Staff did not keep the facility free from an insect

INVESTIGATION FINDINGS:

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On 01/31/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Facility Manager/Med Tech, Bella Lee, and the purpose of the visit was explained.

During today’s visit LPA toured the facility, interviewed Staff (S1-S5), interviewed Residents (R1-R6), and received documents pertinent to the investigation. The documents include Staff Roster, Resident Roster, staff In-Service logs, and receipts OK Exterminators.

The investigation revealed the following:

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240126143235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 01/31/2024

NARRATIVE

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Allegation: Staff did not properly secure the residents medication.

The allegation alleges the medication room was left open, unsupervised, the medication carts were unlocked, and accessible to residents.

During today’s visit, LPA observed staff in the medication room when the door was open. When Staff was dispensing medications to residents, LPA observed Staff close and lock the door. While LPA was in the medication room, LPA observed the medication cart to be closed and locked. LPA did not observe the medication left unattended at any time during today's visit. During interviews with Staff (S1-S5), five (5) out of five (5) stated that when staff leave the medication room it is closed and locked every time. During interviews with S2 and S5, two (2) out of two (2) stated they have seen the medication left open and unattended during an emergency when the Med Tech went to evaluate a resident but they have not seen that for a while and since the training. LPA received and reviewed the In-Service Training that consisted of Medication Training and Medication Room must be Locked at all times training conducted on 01/08/24. During interviews with Residents (R1-R6), six (6) out of six (6) stated the medication room is closed and locked when staff are not in there, and they do not have access to the medications.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240126143235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HAYWORTH TERRACE	FACILITY NUMBER: 198320420
	VISIT DATE: 01/31/2024

NARRATIVE

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Allegation: Staff did not keep the facility free from an insect.

The allegation alleges an insect was observed in the facility kitchen.

During the tour, LPA observed a total of four (4) dead insects in vacant rooms 3, 38, and 43. During the inspection of the kitchen, LPA observed it to be clean and sanitary. LPA did not observe insects in the kitchen or the dining room. LPA received and reviewed receipts for OK Exterminators who provide monthly treatments for cockroaches, bed bugs, and rats. During interviews with Staff (S1-S5), five (5) out of five (5) stated they have not seen insects in the facility for a while. During an interview with S2 stated an exterminator comes out monthly to treat the facility. LPA reviewed In-Service Training conducted on 01/08/24, which consisted of housekeeping and pest control. During interviews with Residents (R1-R6), six (6) out of six (6) stated they have no concerns regarding insects in the facility. During an interviews with Resident (R4 and R6) stated we like the back doors open for fresh air and sometimes a bug will fly in.

An exit interview was conducted with Manager/Med Tech Bella Lee, and a copy of this was provided

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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