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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 05/28/2026
Date Signed: 05/28/2026 04:59:16 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
05/20/2026 and conducted by Evaluator Jose Anguiano
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260520164129
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:CAVIN H YOOFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 51DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Kevin YooTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility did not reveal or make records available upon request.
INVESTIGATION FINDINGS:
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On 05/28/2026, Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced complaint visit and met with Administrator Kevin Yoo.

The investigation consisted of the following: The Department conducted interviews with four staff (S1–S4), five residents (R2–R6), and one witness (W1). Also reviewed records related to the request for former resident (R1’s) records. Records reviewed included the record request email, the facility’s response email, authorization documents, and documents related to the request for R1’s records. Staff and Resident roster.
The investigation revealed the following: Regarding the allegation: Facility did not reveal or make records available upon request. It is being alleged that the facility did not provide R1’s requested records timely and did not provide all requested records.

Please see (LIC9099-C) for report continuation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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 3
Control Number 11-AS-20260520164129
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: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2026
Section Cited
CCR
87468.2(a)(19
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Additional Personal Rights of Residents in...(a)…facilities for the elderly shall have all of the following personal rights:(19) To have prompt access to review all of their records...records shall be provided within two (2) business days…This requirement was not met as evidenced by:
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Administrator agreed to submit a written plan of correction to LPA Jose Anguiano by due date, explaining how the facility will ensure resident record requests are processed and provided within the required timeframe. Emailed to Jose.Anguiano@dss.ca.gov
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Based on interviews conducted and records reviewed, the licensee failed to provide R1’s requested records within two (2) business days. This violation poses/posed a potential personal rights risk 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20260520164129
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: 05/28/2026
NARRATIVE
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Records reviewed revealed: W1 requested R1’s records from the facility on 05/01/2026 at 3:41 PM. Records reviewed also showed the facility sent records to W1 on 05/20/2026 at 12:37 PM. Interviews conducted revealed: W1 requested R1’s resident records, including billing records and other records maintained in R1’s file. W1 stated the records were not provided timely and the records later received on 05/20/26 did not include billing records. During interview, S1 acknowledged there was a delay in the facility’s response to the records request and stated the request was not completed timely.
Based on interviews conducted and records reviewed, the facility did not provide R1’s requested records timely, and the records later provided did not include all requested records. Based on the evidence gathered, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.2(a)(19). A citation is being issued on the attached LIC 9099-D.

An exit interview was conducted, and a copy of this report and appeal rights were provided to the Administrator.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3