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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:31:35 PM

Substantiated


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
05/14/2025 and conducted by Evaluator Elvira Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250514114905
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:
06/18/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Miran BaeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
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On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility.

The investigation consisted of the following:

On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #1-#5 (R1-R5). Additionally, LPA and Aldo Apostol conducted a tour of the facility.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
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 7
Control Number 11-AS-20250514114905
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: 06/18/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not seek timely medical attention for a resident. It is being alleged that a resident had rashes, edema, and was limping, and despite the reports, staff did not seek timely medical attention for the resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that staff did not fail to seek medical attention for a resident, and 1 out of 3 staff interviewed stated they did not know if staff did not seek timely medical attention for a resident in the past. 2 out of 3 staff interviewed stated that a resident never reported needing medical attention to staff. 3 out of 3 staff interviewed stated that staff ensures to seek medical attention for residents in a timely manner when they need it.

On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that they don’t know if staff have failed to seek medical attention for a resident in a timely manner. 5 out of 5 residents interviewed stated that staff do seek medical attention for residents when they need it. 5 out of 5 residents interviewed stated that they did not know if a resident ever reported needing medical attention to staff. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them.

A review of records revealed that R1s daughter (F1) emailed Dr. Whiteman on 11/01/23 letting the doctor know that her mother had swelling in her right leg, below the knee, for over two months. She also sated that her mother had a corn on her right pinky toe, and that her mother reported a 7 out of 10 on the pain scale. On 04/05/24, F1 emailed Dr. Whiteman advising that R1 had an urgent care visit for leg swelling and skin lesions. Medical records from Cedars-Sinai Medica Network dated 11/02/23, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current hyperlipidemia, mixed hyperlipidemia, major neurocognitive disorder (HCC), leg swelling, corn, primary hypertension. Medical records from Cedars-Sinai Medica Network dated 11/03/23, revealed that F1 took R1 to the hospital, and was seen for toe pain, bilateral and tyloma. Medical records from Cedars-Sinai Medica Network dated 04/04/24, revealed that F1 took R1 to the hospital, and was seen for a follow up podiatry evaluation, bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes.

Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250514114905
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: 06/18/2025
NARRATIVE
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Medical records from Cedars-Sinai Medica Network dated 07/12/24, revealed that F1 took R1 to the hospital, and was seen for bilateral lower extremity edema/stasis dermatitis, mycotic toenail changes, bilateral feet and painful tylomas, bilateral 5th toes. Medical records from Cedars-Sinai Medica Network dated 12/13/24, revealed that F1 took R1 to the hospital, and was seen for age-related osteoporosis without current pathological fracture, rash, mixed hyperlipidemia, and primary hypertension.

Although staff interviewed stated that they did not fail to seek medical attention for R1, records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues.

Based on record review, and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited, please see the attached LIC 9099-D.


Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
05/14/2025 and conducted by Evaluator Elvira Gonzalez
COMPLAINT CONTROL NUMBER: 11-AS-20250514114905

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:
06/18/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Miran BaeTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Staff mismanaged residents medication.
Staff dispensed medication not prescribed to resident.
INVESTIGATION FINDINGS:
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On 06/18/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint visit to further investigate the allegations mentioned above and deliver findings. LPA met with Manager, Miran Bae, and the purpose of the visit was explained. LPA was granted entrance to the facility.

The investigation consisted of the following:

On 05/19/25, LPA requested the staff and resident rosters. LPA collected and reviewed the following records for resident #1 (R1): Resident Assessment, Individual Service Plan, Physician’s Report, Identification and Emergency Information, Face Sheet, and Medical Administration Record (MAR) (dated: 03/01/25-03/31/25). LPA conducted interviews with staff #1-#3 (S1-S3) and residents #1-#5 (R1-R5). Additionally, LPA and Aldo Apostol conducted a tour of the facility.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250514114905
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: 06/18/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff mismanaged residents’ medication. It is being alleged that a staff administered Alendronate 70mg to a resident, despite never having been prescribed. It is also alleged that no explanation was given as to how a prescription never prescribed could have been administered. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of staff interviewed stated that staff has not mismanaged a resident’s medication. 3 out of 3 staff interviewed stated that staff dispenses resident’s medication(s) on time and as prescribed by their physician.

On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that staff dispenses their medications on time and as prescribed by their physician. 5 out of 5 residents interviewed stated that staff has not mismanaged their medication. 5 out of 5 residents interviewed stated that they did not know if staff mismanaged a resident’s medication in the past. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them.

Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff dispensed medication not prescribed to resident. It is being alleged that staff administered Alendronate 70mg despite never having been prescribed to a resident. On 05/19/25, between 11:45 AM and 12:15 PM, LPA Gonzalez interviewed S1-S3. Based on interviews conducted, 2 out of 3 staff interviewed denied the allegation. 2 out of 3 staff interviewed stated that they did not know if staff administered Alendronate 70 mg to a resident in the past. An interview conducted with S2 revealed that they did not know of this allegation and denied ever confirming this allegation with a resident’s responsible party.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20250514114905
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: 06/18/2025
NARRATIVE
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On 05/19/25, between 01:15 PM and 2:35 PM, LPA Gonzalez interviewed R1-R5. Based on interviews conducted, 5 out of 5 residents interviewed stated that they did not know if staff dispensed medication(s) not prescribed to a resident in the past. 5 out of 5 residents interviewed stated that. 5 out of 5 residents interviewed stated that they are satisfied with the services being provided to them.

Based on observation, records reviewed, and interviews conducted, the department did not find sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted. Appeal rights and a copy of this report was provided to Manager, Miran Bae.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250514114905
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/25/2025
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Licensee shall ensure that staff seeks medical attention for residents in a timely manner. Licensee to conduct In-service training with staff. Licensee will submit proof of training and a statement aknowledging they reviewed regulation and understood. Licensee to submit POC to LPA Gonzalez by POC due date.
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This requirement is not as evidenced by: Records reviewed revealed that R1 was seen on several occasions at Cedars-Sinai Medica Network for health-related issues. This poses a potential personal rights violation to persons in care.
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7