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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320420
Report Date: 08/08/2026
Date Signed: 08/09/2026 10:50:42 AM

Document Has Been Signed on 08/09/2026 10:50 AM - 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: 54DATE:
08/08/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:56 PM
MET WITH:Hee Yung Park & Juan RosselleTIME VISIT/
INSPECTION COMPLETED:
04:03 PM
NARRATIVE
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On August 8, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at the facility. Upon arrival, the LPA performed a risk assessment and explained that the purpose of the visit was to conduct a health and safety inspection. Licensed Vocational Nurse Hee Yung Park and Maintenance Representative Juan Rosselle greeted the LPA.

A total of 26 resident rooms on the first floor were inspected, specifically rooms #1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, and 70. Additionally, 30 resident rooms on the second floor were inspected, including rooms #18, 19, 20, 21, 22, 23, 25, 26, 27, 29, 30, 31, 34, 35, 38, 40, 41, 42, 43, 49, 74, 75, 76, 77, 78, 79, 80, 82, 84, and 87. A thorough inspection of the dining room, activity room, medication room, and administrative office, along with the exterior surroundings, revealed no bodies of water or obstructions on the premises included (40) mouse bait boxes. The kitchen was found to have a sufficient supply of both perishable and non-perishable food, all of which was properly maintained. Fire extinguishers were charged, and both smoke detectors and carbon monoxide detectors were operational.

The LPA noted that the Emergency Disaster Plan (LIC 610) was posted, along with the Activities Calendar. A functioning landline and internet services were also available. The LPA observed a “Public Scabies Notification Letter” dated July 22, 2026, posted on the main entrance door.

During the inspection, the LPA observed several cans of insecticide and pesticide in rooms #20, #78, and #80. Room #19 contained two sharp scissors lying on the sink basin. Additionally, room #29 had powder detergent in the bathroom.
(Evaluation Report continues LIc 9099-C)
Janae Hammond
Ernand Dabuet
DATE: 08/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2026
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.

LIC809 (FAS) - (09/23)
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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: 08/08/2026
NARRATIVE
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Based on interviews, observations, and record reviews, the licensee violated the California Code of Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies were documented, and an exit interview was conducted with Hee Kyung Park and Juan Rosselle. A copy of this report is provided along with the appeal rights.

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/09/2026 10:50 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/08/2026 at 06:01 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: 08/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2026
Section Cited
CCR
87309(a)(b)

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87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... which could pose a danger to residents are in locked storage and are not left unattended...
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Licensee will adhere to Title 22- 87309(a)(b) and ensure all residents are restricted access from hazardous, toxic chemicals. Submit proof of correction by POC due 08/09/26to attn: Ernand Dabuet at 424-544-1016.
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This requirement was not met as evidenced by: Based on interview and observation, licensee did not ensure to have hazardous toxic chemical, pesticides and scissors in locked storage area. This violation poses/posed an immediate risk to persons in care.
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Corrected during the visit and all hazardous and toxic chemcal items were removed and stored in loced storage.

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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2026


LIC809 (FAS) - (06/04)
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