198320420-5-10-2025-11-AS-JHAD-DHLVKY-20250613163106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 05/10/2025
Date Signed: 05/10/2025 05:15:02 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
04/07/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250407115705

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	198320420
ADMINISTRATOR:	MIRAN BAE		FACILITY TYPE:	740
ADDRESS:	325 N HAYWORTH AVE		TELEPHONE:	(323) 655-3101
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90048
CAPACITY:	111	CENSUS: 48	DATE:	05/10/2025
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Hee Kyung Park		TIME COMPLETED:	11:59 AM

ALLEGATION(S):

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Staff accessed resident's cell phone without permission.
Staff did not respect resident's rights.
Staff served cold food to a resident in care.
Staff opened resident's mail.

INVESTIGATION FINDINGS:

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On May 10, 2025, the California Department of Social Services/Community Care Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Hee Kyung Park, the Licensed Vocational Nurse, greeted the (LPA). (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above.

The investigation included interviews, a collection of records, and an observation of the facility. Interviews were conducted with residents #1- #6 (R1-R6) and staff #1- #5 (S1-S5). The Department reviewed several documents, including the Facility Staff Roster (dated 04/14/25), Resident Roster (dated 04/14/25), Resident #1 (R1)'s service records, Facility Menu (dated 04/01/25 through 04/30/25), and other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

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 6

Control Number 11-AS-20250407115705

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: 05/10/2025

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff accessed resident's cell phone without permission.

The complaint alleged that Resident #1 (R1)’s cell phone was accessed without permission by staff. It was reported that (R1) had left the cell phone with staff while (R1) was being treated at the hospital, and staff had operated the phone and deleted applications and photos. No further information has been provided relating to this allegation.

On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members, identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members claimed that this claim is false. (S1) stated that (R1) left the cell phone for safekeeping in the office while (R1) was treated at the hospital, and no one had tampered with or operated (R1)’s phone. (S1-S2) stated that although we had (R1)’s phone in safekeeping, the staff could not manage it as it required a pass code. (S1-S2) noted that the phone was returned to (R1) after the hospital visit, and the staff did not tamper with the phone.

On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6. Five (5) out of the five (5) resident members have never experienced this situation and cannot corroborate this claim.

On April 7, 2025, between 1:30 PM and 02:45 PM, the Department interviewed the resident member identified as Resident #1 (R1). (R1) claimed that while being treated at a hospital for several days, the office staff had kept (R1)’s phone for safekeeping and had access without permission. Personal photos and applications were deleted from the phone. The office staff had access to the phone since it had no passcode. Additional details could not be provided because it was merely speculation.
The Department audited (R1)’s service file, which included a Personal Rights LIC 613C (dated 08/26/24) and Physician Report LIC 602A (dated 08/26/24), revealed that (R1) is visually impaired. (R1) did not have the required document, Resident Personal Property & Valuables LIC 621.

During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

Based on the gathered information, insufficient evidence supports the stated allegation.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20250407115705

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: 05/10/2025

NARRATIVE

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Allegation #2: Staff did not respect resident's rights.

The complaint alleged that staff did not accord Resident #1 (R1) the resident’s rights. A recent report indicated that (R1) was compelled to engage in activities in the dining room despite expressing a lack of interest in participating. No further information has been provided relating to this allegation.

On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members, identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members stated they could not support this claim. (S1-S5) noted that no residents are forced to participate in activities, whether eating meals or engaging in social activities. The staff is fully aware of the importance of personal rights, emphasizing respect for individuals and ensuring comfortable living conditions. (R1) was often granted the right to stay in the room with meals and did not want to participate with other residents during mealtime, according to (S1).

On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6. Five (5) out of the five (5) resident members expressed that the facility allowed them to choose whether to eat their meals in the dining area or in their room. Participation in activities or meals is voluntary; no one is obligated to participate.

On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed the resident identified as Resident #1 (R1). During the interview, (R1) reported that they were forced to go into the dining room against their will and were taken there by staff members. However, (R1) could not provide specific details about when the incident occurred or the staff member's name.

The Department reviewed staff training records and verified that staff had completed Workplace Sensitivity Training Courses, including ADLs, Resident Behaviors, and Resident Rights.

During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

Based on the gathered information, insufficient evidence corroborates the allegation.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20250407115705

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: 05/10/2025

NARRATIVE

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Allegation #3: Staff served cold food to a resident in care.

It is alleged that the staff served cold food to Resident #1 (R1). Observations suggest that (R1) was repeatedly served food at an unsatisfactory temperature. No further information has been provided relating to this allegation.

On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members reported that they could not validate the claim regarding food temperature. According to Staff #5 (S5), no residents are served food at an unsatisfactory temperature. (S5) explained that the kitchen has a food thermometer used during cooking to ensure food is maintained at safe holding temperatures. Specifically, hot foods should be held above 135 degrees Fahrenheit. (S5) also noted that residents often socialize before eating, which can cause the food to lose heat and become less hot when ready to eat. Additionally, (S5) indicated that residents are encouraged to express dissatisfaction with their food's temperature, and staff will either prepare a new serving or reheat the meal upon request.

On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) of the five (5) resident members claimed to have no issues or concerns with the meals. All of them expressed that their meals had been served at the proper temperature.

On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed a resident member identified as Resident #1 (R1). During the interview, (R1) expressed that there have been occasions when the meals served were not at the proper temperature and were served cold. It appears that (R1) could not provide further insights on this matter.

A review of the facility's Monthly Menu for April 2025 (from April 1 to April 30) included a comprehensive list of all breakfast, lunch, and dinner meals and alternative options. Additionally, an evaluation of staff training for the kitchen showed that personnel completed courses on Food Safety, Kitchen Safety, Appearance Guidelines, Customer Expectations, and Special Diet Considerations. Furthermore, a review of (R1) 's Physician's Report LIC 602A (dated 08/26/24) revealed that (R1) is capable of self-feeding and is not on any special diet.
(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20250407115705

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: 05/10/2025

NARRATIVE

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During investigation visits on April 14, 2025, and April 23, 2025, the Department observed that residents were served lunch soup, pasta, vegetables, salad, and fruit in trays and taken to eat at the table. An observation of trays being served from the kitchen to the table was made in several minutes. An observation of some residents immediately ate the food while others spent leisure time socializing along with their meals. The Department surveyed six residents, and all reported that the food was of good quality and at an adequate temperature.

Based on the gathered information, insufficient evidence corroborates the allegation.

Allegation #4: Staff opened resident mail.

The details of this complaint alleged that staff opened Resident #1 (R1)’s mail. According to the report, staff opened (R1)’s mail without permission. No further information has been provided relating to this allegation.

On April 23, 2025, between 10:15 AM and 12:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) the staff members denied this accusation. (S1-S2) claimed that this accusation is false and that the office staff oversees incoming mail delivery and distribution to residents. (S1-S2) expressed a firm belief that there is no justification for opening residents' mail. They know that such actions violate residents' rights and constitute a federal offense, given that tampering with mail intended for someone else is against the law.

On April 23, 2025, between 10:30 AM and 01:15 PM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) of the five (5) resident members have never encountered any issues with mail tampering while living at this facility. Residents have reported that the office staff is responsible for distributing their mail and confirmed that it remains unopened upon receipt.
On April 7, 2025, between 1:30 PM and 2:45 PM, the Department interviewed a resident member identified as Resident #1 (R1). (R1) mentioned that staff opened their mail, but the Department lacked evidence to confirm the exact date or details surrounding this occurrence.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20250407115705

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: 05/10/2025

NARRATIVE

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The Department audited the service file of (R1), which included a Personal Rights LIC 613C (dated 08/26/24). Staff training records for staff members had completed Workplace Sensitivity Training Courses that covered Activities of Daily Living (ADLs), Resident Behaviors, and Resident Rights.

During investigation visits on April 14, 2025, and April 23, 2025, the Department noted that mandated posters outlining Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility.

Based on the information collected, insufficient evidence supports the stated allegation.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted with the Licensed Vocational Nurse, Hee Kyung Park, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2025

LIC9099 (FAS) - (06/04)

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