198320420-6-5-2025-11-AS-EMAZ-DK4UAZ-20250731152532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 06/05/2025
Date Signed: 06/05/2025 12:41:33 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
03/21/2025 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20250321122706

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: 49	DATE:	06/05/2025
		UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	MIRAN BAE		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff can not effectively communicate with resident in care.
Facility staff do not provide resident with activities.
Facility staff are not assisting with soiled diapering in a timely manner.
The resident's grooming needs are not being met.
Facility staff did not maintain a comfortable temperature for residents.

INVESTIGATION FINDINGS:

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On 06/05/2025, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent visit regarding the above allegations. LPA met with the Manager Miran Bae and the purpose of the visit was explained.

The investigation included the following steps: On March 27, 2025, Licensing Program Analyst (LPA) Antonine Richard conducted an initial unannounced complaint visit. The investigation involved interviews, the collection of records, and a tour of the facility. LPA Richard interviewed three staff members #1-3 (S1, S2, and S3), the Administrator (A1), Hien Hwang, and five residents #1-5 (R1 to R5).
Several documents were reviewed and obtained during the visit, including the Facility Staff Roster, Resident Roster, Identification and Emergency Information for Resident #1 (R1), Medical Consent Form, Appraisal/Needs and Service Plan, Personal Rights, Medication Administration Records, Physician's Report, scheduled activities, and appointments with the foot doctor, along with other relevant records related to the complaint.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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-20250321122706

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: 06/05/2025

NARRATIVE

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Allegation #1: Facility staff cannot effectively communicate with resident in care.

The complaint alleges that the staff speak Korean, and the residents speak Japanese, which often results in the residents being left alone.

On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. Hien stated that the caregiver does speak English and assists all residents with their daily needs.

Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed five Residents, #1-5 (R1-R5). Four out of the five residents denied the allegation and indicated that they had no problems communicating with the staff, even though they primarily speak Korean.

Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three staff members #1-3 (S1-S3). All three staff members denied the allegation, asserting that everyone who works there speaks English and is fully capable of assisting the residents in their care. During the visit, LPA observed the staff communicating effectively in English with both LPA and the residents without any difficulty. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to answer the questions posed.

Based on information gathered and interviews, LPA did not find sufficient evidence to support the allegation “Facility staff cannot effectively communicate with residents in care”, therefore, the allegation is unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20250321122706

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: 06/05/2025

NARRATIVE

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Allegation #2: Facility staff do not provide a resident with activities.

The complaint alleges that the resident was frequently left alone in her wheelchair at a table without any activities to engage in, such as reading a book or watching TV. On March 27, 2025, LPA Richard interviewed Administrator Hien Hwang (A1), who denied the allegation. Hwang stated that all residents have a TV in their rooms, allowing them to watch any show in any language they choose. Additionally, there is a large screen TV in the activities room, and daily activities are scheduled for all residents to participate in if they wish.

Between 10:00 AM and 12:30 PM on the same day, LPA Richard interviewed five Resident #1-5 (R1-R5). Four out of the five residents denied the allegations and expressed a preference for watching TV in their rooms. They also indicated that the facility provided them with daily activities. Additionally, between 10:00 AM and 12:30 PM, LPA Richard interviewed three Staff members, #1-3 (S1-S3). All three staff members denied the allegations and stated that the facility has seven days of activities scheduled for all residents.

On March 27, 2025, during a review of the activities schedule, LPA Richard confirmed that the facility offers activities every day from 9:00 AM to 3:00 PM. Furthermore, on the same day, LPA Richard observed staff and residents participating in current events activities in the activity room. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the assistance of an interpreter; however, R1 was unable to answer the questions posed. Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff do not provide residents with activities,” therefore, the allegation is deemed unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20250321122706

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: 06/05/2025

NARRATIVE

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Allegation #3: Facility staff are not assisting with soiled diapering in a timely manner.

This complaint alleges that residents are often left in soiled diapers for extended periods without being changed. On March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed five residents (R1-R5). Four out of the five residents denied the allegation and stated that they are changed every one to two hours each day.

LPA Richard also interviewed three staff members (S1-S3), all of whom denied the allegation and reported that residents are changed every two hours, or sooner if an accident occurs before or shortly after the scheduled change. The Administrator (A1) confirmed that residents are checked every one to two hours.

A review of the changing schedule from February 1, 2025, to March 30, 2025, showed a list of residents who wear diapers along with the times they are scheduled to be changed. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked.

Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that “facility staff are not assisting with soiled diapering in a timely manner,” therefore, the allegation is deemed unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20250321122706

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: 06/05/2025

NARRATIVE

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Allegation #4: The resident’s grooming needs are not being met.

The complaint alleges that the resident’s toenails are often not trimmed. On March 27, 2025, between 10:00 AM and 12:30 PM, LPA Richard interviewed the Administrator, who denied the allegation. The Administrator stated that the facility has a podiatrist who visits every month to provide podiatry services to the residents. During the same time frame, LPA Richard interviewed five residents (R1-R5). Four out of the five residents denied the allegation, stating that a pedicurist comes every month to assist them with their nails and toes.

Additionally, LPA interviewed three staff members (S1-S3) on March 27, 2025, between 10:00 AM and 12:30 PM. They also denied the allegation and confirmed that a podiatrist visits the facility each month to service the residents' nails and toes.

Records reviewed by LPA, including the facility's foot doctor schedule dated February 13, 2025, indicated that residents receive podiatric services regularly. Furthermore, LPA observed that most residents' feet were well-trimmed and clean. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked.

Based on the information gathered and interviews, LPA Richard did not find sufficient evidence to support the allegation that the resident’s grooming needs were not being met. Therefore, the allegation is deemed unsubstantiated.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20250321122706

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: 06/05/2025

NARRATIVE

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Allegation #5: Facility staff did not maintain a comfortable temperature for residents.

The complaint alleges that the resident's room is covered with wallpaper, preventing proper heat flow, which keeps the resident's room cold. On March 27, 2025, between 10:00 AM and 12:30 PM, the Licensing Program Analyst (LPA) interviewed A1, who denied the allegations. A1 stated that each room is equipped with a heat control system that allows residents to adjust the temperature themselves.

During the same time frame, LPA Richard interviewed five residents residents (R1-R5). Four out of the five residents denied the allegations, indicating that their rooms were comfortable and that they could turn the heater on or off as needed.

Additionally, the LPA interviewed three staff members (S1-S3) on March 27, 2025, between 10:00 AM and 12:30 PM, and they also denied the allegations.

Furthermore, LPA visited five residents' rooms and requested to turn on the heaters during each visit. The rooms were not cold, and the hot air from the heaters was functioning properly. Later, at 1:30 PM on March 27, 2025, LPA Richard attempted to interview Resident #1 (R1) with the help of an interpreter; however, R1 was unable to answer the questions asked.

No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Manager Miran Bae.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC9099 (FAS) - (06/04)

Page: 6 of 6