<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 05/09/2025
Date Signed: 05/09/2025 04:30:56 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, 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
03/24/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250324165545
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: 48DATE:
05/09/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Miran Bae/ManagerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff left resident in dirty clothes for a period of time.
Staff not providing resident with nutritious meals.
Staff tied up resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/9/2025 LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Miran Bae / Manager. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#3) and Resident’s interviews (R#1-R#5) and Witness 1 (W#1). LPA obtained and reviewed the following documents: Resident Roster (dated May/2025), staff roster (dated March/25),(R#1)’s Identification and Emergency Information or LIC 601 dated:3/22/20, (R#1)’s Physicians Report for residential Care Facilities for the Elderly (RCFE) or LIC 602A dated:3/19/25, (R#1)’s Admission Agreement dated:3/22/20, use of the interpreter line (760-640-0562), a Health and Safety check of the facility’s kitchen and Facility’s Annual Training dated:1/26/25.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
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 5
Control Number 11-AS-20250324165545
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: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Investigation Revealed the Following:

Allegation: Staff left resident in dirty clothes for a period of time.

The details of the complaint alleged that (R#1) has been left in dirty clothes for an extended time.



On May 9, 2025, at approximately 1:00 PM, during the records review, LPA Iniguez observed (R#1)’s Admission Agreement dated:3/22/20, in the agreement it is written that the (R#1) can be assisted with their Activities of Daily Living (ADL’s) when necessary. In addition, LPA Iniguez observed facility’s Annal Training dated:1/16/25, LPA Iniguez observed that one of the annual topics is Residents Rights.

On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that she knows the resident’s personal rights. In addition, (A#1) stated that (R#1) has never been left in dirty clothes for an extended period.

On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call. In addition, LPA Iniguez observed that (R#1) was wearing clean clothes and not dirty.

On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they are treated with dignity and respect. In addition, (4) out of (4) residents stated that they have never been left in dirty clothes for an extended period.



On May 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated they know the resident’s rights. In addition, (3) out of (3) facility staff stated that (R#1) has never been left in dirty clothes for an extended period.

Evaluation Report continues LIC 9099-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250324165545
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: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that in the times they came and visited (R#1), they had never observed (R#1) with dirty clothes on.

Allegation: Staff not providing resident with nutritious meals.

The details of the complaint alleged that facility is not providing nutritious meals to (R#1).

On May 9, 2025, at approximately 11:00 AM, during a Health and Safety Check of the facility’s kitchen, LPA Iniguez observed that the facility’s food meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council.



On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that the food the facility serves to (R#1) and other residents in care is nutritious.

On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call.

On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that the food the facility serves is nutritious.

On March 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that the food the facility serves to (R#1) and other residents in care is nutritious.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250324165545
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: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that the food they served to (R#1) is nutritious for the most part.

Allegation: Staff tied up resident.

The details of the complaint alleged that (R#1) has been tied to their wheelchair.

On May 9, 2025, at approximately 9:00 AM, during an Interview with the Administrator (A#1), she stated that (R#1) had not been tied to their wheelchair.



On May 9, 2025, at approximately 10:00 AM, during an interview with (R#1) using the interpreter line (Focus Interpreter with interpreter Miza#bb249), LPA Iniguez requested the interpreter to ask (R#1) if they could hear. The interpreter posed the question in Japanese, but (R#1) responded, “I don’t know.” LPA Iniguez then asked the interpreter to inquire if (R#1) knew what day it was. The interpreter relayed the question, and (R#1) answered, “I don’t know.” Following this, LPA Iniguez concluded the telephone call. In addition, LPA Iniguez observed (R#1) is not tied up on their wheelchair.

On May 9, 2025, at approximately 10:30 AM, during interviews with residents (R#2-R#5), (4) out of (4) stated that they have never been tied to their wheelchairs by facility staff.

On May 9, 2025, at approximately 11:00 AM, during interviews with facility staff (S#1-S#3), (3) out of (3) stated that they do not tie (R#1) to their wheelchair.

On May 9, 2025, at approximately 12:00 PM, during an interview with witness 1 (W#1), they stated that the times they come and visit (R#1), they have never seen (R#1) tied to their wheelchair.


Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250324165545
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: 05/09/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.





An exit interview was conducted, and a copy of the Complaint Report was given to Miran Bae / Manager.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5