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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320420
Report Date: 01/22/2026
Date Signed: 01/22/2026 04:46:44 PM

Document Has Been Signed on 01/22/2026 04:46 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:
CAVIN H YOOFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY: 111CENSUS: 66DATE:
01/22/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Cavin YooTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On January 22, 2026, Licensing Program Analyst (LPAs) Ernand Dabuet, Lizeth Villegas, Sparkle Day and Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Executive Director Cavin Yoo. LPA explained the purpose of today’s visit. The facility is licensed to serve (111) non-ambulatory elderly adults ages 60 and above. The facility is approved for (25) hospice residents. Currently, the facility has (12) residents on hospice care.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (81) resident bedrooms. Each room has a bathroom in the unit. The facility houses an activity room, dining area, kitchen, administrative offices, and outside patio area.

LPA Dabuet toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #18; #20; #22; #40; #48; #74; #86; #62, #65 and #49. The water temperature range from 95.0 - 121.5 degrees F. and room temperature range from 66 - 70 degrees F. and smoke and carbon monoxide are all in operating condition.

LPA Dabuet observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged. A review of Fire Drills were completed 12/19/25 . Several working landline phones are available on-site. A review of Medication Administration Records found to be in order and accurate.
Evaluation Report continues on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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: 01/22/2026
NARRATIVE
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During the visit LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters, including the Activities Calendar and Food Menu, were posted.

An audit of resident's service records for resident #1-#6 (R1-R6) and staff personnel records for staff #1-#6 (S1-S6). The facility is current on Community Care Licensing annual fees. The facility has a current administrator certificate on file for Cavin Yoo #6078367740 09/12/2025 through 09/11/2027 RCFE. The facility has a Liability Insurance Certificate valid with policy # HOO76K0023601 effective 11/26/25 through 11/26/26.

Deficiencies:
  • The emergency call button is non-operational in the following rooms: #49, #20, #22, and #86.
  • There is no emergency call button available in rooms #62 and #18.
  • The toilet seat cover is missing in room #22.
  • Disinfectant and toxic chemical sprays were observed in rooms #17 and #65.
  • Scissors and other hazardous objects were found in room #18.
  • Staff members #2, #3, and #5 do not have CPR/First Aid certifications on file.
  • There is no Appraisal/Needs Service Plan LIC 625 on record for residents #1, #2, #3, and #5.
  • Staff members #4 and #6 do not have TB Test and Health Screening results on file.
  • Residents in rooms #18 and #65 have prescribed medications stored in their rooms, but they are unable to handle medications according to LIC 602A guidelines.
  • The hot water temperature measured between 95°F and 97°F in rooms #18, #20, and #2.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Cavin Yoo.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/22/2026 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/22/2026 at 12:18 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: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows:
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for the water testing in 9 out of 10 rooms tested at between 95.0 - 97.0, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Licensee will adhere to Title 22 Reg 87303 at all times. Licensee will ensure that water supply remain in compliance with hot water temperature of not less than 105 degrees F and not more than 120 degree F. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General
(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. Staff #2, #3, and #5 did not have First Aid/CPR on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Licensee will always adhere to Title 22 Reg 87411(c)(1). Licensee will ensure all staff who have direct care with residents must have completed First Aid/CPR completed. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/22/2026 at 12:46 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: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified room #17 #65 and #18 had disfectants, toxic chemicals and scissors accessible in their rooms. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Licensee will always adhere to Title 22 Reg 87309(a)(1). Licensee will ensure shall ensure that all resident in care do not have access to hazardous, toxic or sharp objects at all times. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care (h)(2)
(h)The following requirements shall apply to medications which are centrally stored:
(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified room #18 and #65 had prescription medication stored in their rooms. Resident are not able handle medications or store meds. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2026
Plan of Correction
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Licensee will always adhere to Title 22 Reg 87465(h)(2). Licensee will ensure that all medications are stored in locked storage and not accessible to residents in care. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/22/2026 at 12:47 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: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified Staff #4 and Staff #6 did not have TB or Health Screening on file. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Licensee will always adhere to Title 22 Reg 87411(f). Licensee will ensure that all staff have Health Screening and TB on file. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/22/2026 at 12:47 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: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation], the licensee did not comply with the section cited above. LPA observed a non working toilet seat cover for room #22. This violaiton which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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Licensee will always adhere to Title 22 Reg 87303(e)(6). Licensee will ensure that all rooms have working bathing and toilet supplies in working condition. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified no Needs Service Plan Appraisal for Resident #1, #2, #3, #5. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2026
Plan of Correction
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3
4
Licensee will always adhere to Title 22 Reg 87456(a)(2). Licensee will ensure all residents in care must have Needs Service Plan/Appraisal on file. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/22/2026 04:47 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 01/22/2026 at 01:20 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: 01/22/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
873039i(1)(A)(B)(C)
87303 Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
(C) Identify the specific resident living unit.

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. LPA identified in 7 out of 10 rooms did not have operable or missing emergency call buttons. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2026
Plan of Correction
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2
3
4
Licensee will always adhere to Title 22 Reg 87303(I)(1) (A)(B)(C). Licensee will ensure that all resident's room have operable emergency call button. Proof of correction must be sent to LPA ernand.dabuet@dss.ca.gov
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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/22/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2026


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