198320420-5-15-2025-11-AS-UCOL-DHTNW6-20250620104859

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:22:33 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
12/12/2024 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20241212132109

FACILITY NAME:	HAYWORTH TERRACE		FACILITY NUMBER:	198320420
ADMINISTRATOR:	PARK, MAN		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:	05/15/2025
		UNANNOUNCED	TIME BEGAN:	09:06 AM
MET WITH:	Miran Bae, Manager		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Staff are unable to effectively communicate with resident to ensure their needs are met
Staff do not ensure that resident is adequately fed
Staff do not treat resident with dignity or respect

INVESTIGATION FINDINGS:

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On 05/15/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility. LPA was met by staff four, Miran Bae Manager (S4), and the purpose of the visit was explained.
The investigation consisted of the following:
On 12/20/24 LPA requested and reviewed facility documents; including resident and staff roster, three (3) resident physician's report and emergency ID's, three (3) staff training's history and toured the facility. LPA interviewed five (5) out of fifty (50) residents and three (3) out of thirty-one (31) staff. On 05/15/25 LPA requested resident and staff roster (dated 03/25), reviewed two (2) monthly menu's, resident's discharge paperwork of the date in question and facilities' verification a resident is no longer residing at the facility. LPA interviewed two (2) residents and two (2) staff.
The investigation revealed the following: Regarding the allegation “Staff are unable to effectively communicate with resident to ensure their needs are met”, it has been alleged that the facility is Korean owned, and run, which makes it difficult for the residents who do not speak Korean. Report continues, see LIC9099-C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241212132109

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: 05/15/2025

NARRATIVE

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Interviews revealed that four (4) out of seven (7) residents and all five (5) staff do not agree the allegation has taken place. LPA observations revealed that, during 12/20/24 and 05/15/25 visits, three (3) out of five (5) staff speak English. On 05/15/25 LPA observed the following: two (2) staff displayed the ability to understand resident's needs in English, along with body-language, and provide the resident assistance as requested through practice sessions. Record reviews have shown three (3) staff files to be current and staff training's regarding resident care has been met. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation “Staff do not ensure that resident is adequately fed”, it has been alleged that a resident was not offered any food upon their discharge back to the facility. Record reviews revealed that there is a menu that is kept current, which also display the alternative options available if a resident does not want to eat the current menu item. During LPA's visit on 12/20/24, LPA observed a black-bean and rice porridge with drinks for lunch. On 05/15/25, LPA observed a hamburger with pickled vegetables on the side with drinks for lunch. Interviews revealed that four (4) out of seven (7) residents and all five (5) staff do not agree the allegation has taken place. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
Regarding the allegation "Staff do not treat resident with dignity or respect.", it has been alleged that a resident does not feel their level of dignity or respect are being met. Interviews revealed that five (5) out of seven (7) residents and all five (5) staff disagree with the allegation. Record reviews revealed that three (3) staff files to be current and staff training's regarding resident care has been met. Based on record reviews, LPA observations and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

During today's visit, there have been zero (0) citations provided.

An exit interview was held with staff four, Miran Bae Manager (S4), and a copy of this report was provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025

LIC9099 (FAS) - (06/04)

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