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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 05/01/2026
Date Signed: 05/04/2026 09:35:21 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
11/10/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251110142021
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 46DATE:
05/01/2026
UNANNOUNCEDTIME BEGAN:
07:59 AM
MET WITH:Terri HanTIME COMPLETED:
04:58 PM
ALLEGATION(S):
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Resident sustained multiple fractures while in care.
Staff did not to seek timely medical attention for the resident in care.
INVESTIGATION FINDINGS:
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On May 1, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial unannounced complaint visit. Licensed Vocational Nurse, Hee Kyung Park, greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegations mentioned above.

The investigation consisted of the following: The complaint was referred to the California Department of Social Services Investigation Bureau for investigation and was assigned to Investigator Sonia Torre.
Records subpoenaed included Los Angeles Fire Department Records and 9-1-1 Audio Records (dated 12/01/25), Cedars Sinai Medical Center Records (dated 12/12/25), Olympica Convalescent Hospital Records (02/09/26), California Department of Public Health Records (dated 02/09/26), Starline Hospice Records (dated 02/18/26), Photographs taken by Facility Staff (dated 02/09/26), Patient Care Report (dated 11/09/25). Furthermore, the investigator conducted interviews with Staff #1- #8(S1-S8), Witness #1-W#2 (W1-W2), and Resident #2-#4 (R2-R4).
(Evaluation Report continues LIC 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
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
Control Number 11-AS-20251110142021
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: 05/01/2026
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident sustained multiple fractures while in care.

It is alleged that the facility staff failed to provide adequate supervision for Resident #1 (R1), who sustained multiple fractures while in their care. Reports indicate that (R1) was admitted to the hospital following an unwitnessed fall. Further information revealed that (R1) suffered various traumatic injuries, including pneumocephalus, subdural hematoma, epidural hematoma, and a closed facial fracture, all consistent with a single fall. No additional details regarding this incident are available.

Resident #1 (R1) was admitted to Hayworth Terrace on September 15, 2025, as documented in the facility’s Residential Care Admission Agreement (dated 09/15/25). On November 9, 2025, (R1) was transferred to Cedars-Sinai Hospital for treatment of injuries sustained in a fall.

On January 13, 2026, February 9, 2026, February 12, 2026, February 23, 2026, between 09:40 AM and 02:50 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). (8) eight out of eight (8) could not corroborate this claim. On November 9, 2026, (R1) experienced a fall incident resulting in head injuries, necessitating treatment at Cedars Sinai Hospital. (S1) reported discovering (R1) lying by the exterior stairway and believed (R1) had fallen down the stairs, though the specifics of the fall—such as the number of steps—remain unclear. (S1) emphasized that (R1) requires constant supervision since (R1) frequently moves around the facility. Notably, (4) out of (8) staff members corroborated that (R1) has a history of unwitnessed falls, typically resulting in minor injuries. All staff members interviewed agreed that (R1) suffers from Major Neurocognitive Disorder (NCD) and is physically fragile. Additionally, (S7) confirmed that (R1) lacked a Physician's Report LIC 602A, or any formal medical assessment, as (R1) was categorized as a "temporary" resident.

On January 13, 2026, between 10:15 AM and 12:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #4 (R2-R4). Three (3) out of three (3) could not support this claim. All residents expressed they had no concerns about the level of care and supervision provided by staff. Resident #1 (R1) was unavailable for interview due to death.

On November 26, 2025, and February 23, 2026, between 09:36 AM and 03:31 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2).

(Evaluation Report continues LIC 9099-C)

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20251110142021
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: 05/01/2026
NARRATIVE
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Two (2) out of two (2) witness members were able to corroborate the claim. (W1) reported that (RI) had (NCD) but could walk independently. (R1) lost significant weight and appeared frail during (W1’s) visits. On November 9, 2025, (W1) learned that (R1) had fallen and required, but was initially stable. The next day, the hospital reported a brain bleed. After a week in the ICU, (W1) chose comfort-focused treatment. (R1) was moved to a skilled nursing facility and passed away on November 21, 2025. (W2) pointed out that the injuries exhibited by (R1) at the hospital were inconsistent with a simple ground-level fall. Notably, staff discovered (R1) lying at the foot of a stairway. (W2) emphasized that, given this context, it is entirely apparent that the injuries resulted from a fall down the stairs, which would account for the observed severity.

A review of the facility's records revealed the absence of a Physician's Report, which should have included essential information on medication, medical diagnoses, and physical restrictions, to assess whether the facility could provide the appropriate level of care for Resident #1 (R1). Additionally, the Needs and Services Plan was not complete and failed to identify any of (R1's) mental, physical, or health needs.

Furthermore, an examination of Cedars Sinai Medical Records (dated 12/12/25) verified that (R1) had been diagnosed with multiple severe traumatic brain injuries and facial injuries including bilateral frontal subarachnoid hematomas (8mm right, 4mm left), a bilateral frontal subarachnoid hemorrhage, and a left temporal epidural hematoma (9mm). There are also displaced fractures in the left zygomatic arch, frontal and anterior temporal bones, left orbital wall, and left maxillary sinus, as well as a nondisplaced C6 articular pillar fracture, a displaced right pubic root fracture, and a closed left fifth rib fracture.

During the investigation, records were reviewed, and interviews were conducted with both residents and facility staff. An inspection also found that no surveillance cameras were installed, either inside or outside, to monitor residents. Moreover, it was noted that the stairways leading to the second floor were accessible, which posed safety risks.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

Allegation #2: Staff did not to seek timely medical attention for the resident in care.

It is alleged that the facility staff failed to provide timely medical attention for Resident #1 (R1). Reports indicate that (R1) experienced an unwitnessed fall on November 9, 2025, resulting in multiple fractures and injuries.

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20251110142021
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: 05/01/2026
NARRATIVE
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Further report indicated (R1) did not receive appropriate medical care in a timely manner and received only basic care from facility staff. No further details regarding this incident are available.

On January 13, 2026, February 9, 2026, February 12, 2026, February 23, 2026, between 09:40 AM and 02:50 PM, the Department interviewed staff members identified as Staff #1 through Staff #8 (S1-S8). Eight (8) out of the eight (8) staff members confirmed that (R1) experienced an unwitnessed fall and sustained injuries early in the morning on November 9, 2026. On the morning of November 9, 2026, (R1) was found on the floor by the stairway, bleeding and injured at approximately 9:00 AM. (S1) reported that (R1) was distressing, appearing "in bad shape" and "kind of unresponsive," with visible facial injuries. (S1 and S2) helped (R1) back to (R1’s) room and provided only minimal care, such as wiping the blood and applying a bandage to (R1's) head. Neither (S1) nor (S2) reported this serious incident to management or contacted (R1's) primary physician.

At around 11:30 AM, (S3) entered (R1's) room and discovered them sitting on the bed with a bandage still wrapped around (R1's) head. Observing continued bleeding, (S3) replaced the bandage. Later, around 3:00 PM, (S4) found (R1) lying on the floor of (R1’s) room, the bandage missing. (S4) noticed (R1's) eyes were shut, discolored, and swollen, which raised concerns that (R1) may have suffered another fall. (S4) immediately informed (S3) and insisted that a 9-1-1 call is necessary. (S1-S3) stated that 9-1-1 was not called after (R1) fell because staff were instructed to notify the Medication Technician for assessment and to notify management. (S1-S2) did not consider (R1) needed medical attention since (R1) was able to get up independently, despite having facial injuries and bleeding.

On January 13, 2026, between 10:15 AM and 12:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #4 (R2-R4). Three (3) out of three (3) could not support this claim. All residents expressed they had no concerns about the level of care and supervision provided by staff. Resident #1 (R1) was unavailable for interview due to death.

On December 1, 2026, at 10:27 AM, the Department received audio calls from Emergency Medical Services (EMS) and 9-1-1. The initial 9-1-1 call was made at approximately 3:24 PM, reporting that (R1) had experienced a fall from a standing position. Units were dispatched at 3:26 PM and arrived at the facility by 3:34 PM. At 3:52 PM, (EMS) transported (R1) to Cedars Sinai Hospital.

(Evaluation Report continues LIC 9099-C)

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20251110142021
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: 05/01/2026
NARRATIVE
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The Department reviewed records consisting of: Unusual Incident Report/Injury Report (dated 11/09/26); Client/Resident Face Sheet; Identification and Emergency Information; Admissions Agreement (dated 09/15/25); Consent for Emergency Medical Treatment (dated 09/15/25); Appraisal/Needs and Services Plan; and Medication Administration Record. Further review of Los Angeles Fire Department Records (dated 12/01/25), the 9-1-1 Audio Call (dated 12/01/25), Cedars Sinai Medical Records (dated 12/12/25), and Patient Care Report (dated 11/09/25) revealed that the facility failed to provide timely medical attention to (R1), who sustained multiple fractures and head injuries during a fall.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099 D).

An exit interview was conducted with Terri Han, and copies of the report and appeal rights were provided.

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 5 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
11/10/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251110142021

FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 46DATE:
05/01/2026
UNANNOUNCEDTIME BEGAN:
07:59 AM
MET WITH:Terri HanTIME COMPLETED:
04:58 PM
ALLEGATION(S):
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Staff are unable to effectively communicate with emergency response agency.
INVESTIGATION FINDINGS:
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On May 1, 2026, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted subsequent unannounced complaint visit. Terri Han Assistant and Miran Bae House Manager greeted the (LPA). (LPA) explained the purpose of the visit is to deliver the findings for the allegation mentioned above.

The investigation consisted of the following: A review of Facility Personnel Roster (dated 05/01/26), Facility Resident Roster (dated 05/01/26), LA City Fire Department (EMS) Records (date 12/01/26), Cedar Sinai Medical Records (dated 12/01/25), Admission Agreement (dated 09/15/25) Appraisal/Needs and Service Plan, Resident Face Sheet, Identification and Emergency Information and other pertinent records associated with this complaint. Interviews conducted with Staff #6-#9 (S6-S9) and Resident #2-#8 (R2-R8).

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20251110142021
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: 05/01/2026
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #3: Staff are unable to effectively communicate with emergency response agency.

It is alleged staff are unable to communicate with Emergency Response agency effectively. It is reported that the Los Angeles Fire Department was unable to communicate effectively with staff due to lack of English-speaking personnel and only spoke Korean. No further details regarding this incident are available.

Reports indicate that Resident #1(R1) was admitted to the hospital following an unwitnessed fall. Further information revealed that (R1) was transported by Emergency Medical Services (EMS) on November 9, 2025, to Cedars Sinai Medical Center Hospital.

On May 1, 2026, 9:30 AM and 12:30 PM the Department interviewed staff member identified as Staff #6 through Staff #9 (S6-S9). Four (4) out of the four (4) staff members could not support this claim. (S6) claimed that there is always an English-speaking staff to assist with residents, visitors and agencies. (S1) claimed that (6) out of (26) personnel staff member are fluent English communicators. While the other personnel staff are fluent in Korean or Spanish. (S9) who was present during the incident on November 9, 2025, with (R1) assisted with communications with (EMS) and stated there were no issues with communications with the (EMS) authorities.

On January 13, 2026, and May 1, 2026, between 10:15 AM and 01:30 PM, the Department interviewed residents identified as Resident #2 through Resident #8 (R2-R8). Eight (8) out of three (8) could not corroborate this claim. Residents are satisfied with the care and supervision of the staff, noting that communication effectively meets their needs. (R5-R8) values the diverse language support, which enables smooth, uninterrupted care for residents.

An analysis review of the Facility Resident Roster (dated 05/01/26) shows diversity among residents: 31% primarily communicate in Korean, and 69% primarily communicate in English. A further analysis of the Personnel Staff Roster (dated 05/01/26) shows that only 4.3% of the staff are proficient in English, whereas 95.7% are fluent in either Korean or Spanish. The staffing is designed to effectively meet the needs of their predominantly Korean-speaking residents, ensuring better communication and care.

Based on the information gathered from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. The allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

An exit interview was conducted with Terri Han and copies were provided.

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

DATE: 05/01/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20251110142021
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: 05/01/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2026
Section Cited
CCR
87466
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87466 – Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance...observation reveals unmet needs… brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidence by
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Licensee has agreed to a (POC). The facility will provide in-service training to all staff regarding the cited regulation. Additionally, the facility will develop a plan for residents identified as at risk of falling and submit it to the assigned LPA by May 2, 2026.
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Based on interviews and record reviews, the facility did not ensure that (R1) received timely medical attention after a fall, allowing more than 6 hours to pass before seeking emergency services. This poses an immediate health and safety risk to residents in care.
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Type A
05/02/2026
Section Cited
CCR
87468.1(a)(2)
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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: (2)To be accorded safe, healthful and comfortable accommodations...
This requirement is not met as evidence by
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Licensee has agreed to a (POC). The facility will provide in-service training to all staff regarding the cited regulation. Additionally, the facility will develop a plan for residents identified as at risk of falling and submit it to the assigned LPA by May 2, 2026.
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Based on interviews and record reviews, the facility did not ensure that (R1) was free from neglect and received safe accommodations after a fall. As a result of this failure, the resident sustained multiple fractures and injuries. This violation poses an immediate health and safety risk to residents 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: 05/01/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 8