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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 07/17/2026
Date Signed: 07/17/2026 04:06:20 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
07/10/2026 and conducted by Evaluator Jose Anguiano
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260710145112
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: 54DATE:
07/17/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Terri HanTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility locked residents in their rooms
Facility did not report scabies outbreak
Facility did not have personal protectve equipment for outbreak
INVESTIGATION FINDINGS:
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On 07/17/2026 around 9:00AM, Licensing Program Analyst (LPA) Jose Anguiano and Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit. LPA met with Terri Han and spoke to Administrator Cavin Yoo over the phone and the purpose of the visit was explained.

The investigation consisted of the following: The Department collected resident roster, staff roster, 4 residents physicians reports, and R1-R2 face sheets. The investigation revealed the following: Regarding the allegation facility locked residents in their rooms it is being alleged that residents who were under isolation were locked in their rooms. Interviews conducted revealed the following: 3 out of 5 staff disagreed with the allegation (S2, S3, S5). 2 out of 5 staff disagreed (S1, S4). S2 indicated locking residents (R1-R2) doors to their rooms due to dementia behaviors.

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

DATE: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
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 4
Control Number 11-AS-20260710145112
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: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2026
Section Cited
CCR
87705(5)
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87705 Care of Persons with Dementia (5) Interior and exterior space shall be available on the facility premises to permit residents with dementia to wander freely and safely.
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Licensee will adhere to tittle 22, 87705 and ensure all residents are not locked rooms and free to wander in the interior premises and email plan of corrections to LPA Anguiano. Jose. Anguiano@dss.ca.gov
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This requirement is not met as evidenced by: Based on observations and Interviews R1 and R2 are both ambulatory residents with dementia restricted in their locked rooms. This violation poses/posed an immediate health, safety, or personal rights risk to persons in care.
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Type B
07/24/2026
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(2) Occurrences, such as epidemic outbreaks...which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours... to the licensing agency and to the local health officer when appropriate.
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Licensee will adhere to tittle 22, 87211 and ensure that reporting requirements are met within tittle 22 requirements and email plan of corrections to LPA Anguiano. Jose. Anguiano@dss.ca.gov
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This requirement is not met as evidenced by: Based on Interviews and records reviewed Licensee did not ensure to notify Departmental agencies regarding scabies outbreak within 24 hours. Which poses/posed a potential health, safety, or 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.
SUPERVISOR'S NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260710145112
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: 07/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2026
Section Cited
CCR
87470(2)
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87470 Infection Control Requirements (2) All staff…direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents…through skin…PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.
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Licensee will adhere to tittle 22 87470 and ensure that all PPE supplies are fully stocked in the facility and email plan of corrections to LPA Anguiano. Jose. Anguiano@dss.ca.gov
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This requirement is not met as evidenced by: Based on Interviews and observations Licensee did not have complete inventory of supplies stocked of PP. Which poses/posed a potential health, safety, or 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.
SUPERVISOR'S NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260710145112
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: 07/17/2026
NARRATIVE
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2 out of 8 residents were not interviewed due to their health condition (R1-R2). (R3-R4) were no longer at the facility and as a result not interviewed. 3 out of 8 residents agreed (R5, R6, R8) while 1 out of 8 disagreed (R7). Observations revealed the following: On 07/17/2026 at 11:16AM, The Department observed 2 residents (R1-R2) room numbers 59 & 62 locked in their rooms and only staff had access to unlock the rooms. Based on the evidence gathered, interviews conducted, and observations, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). Regarding the allegation, Facility did not report scabies outbreak it is being alleged that the facility did not report the scabies outbreak to the appropriate Departmental agencies and did not follow residential infection control plan. Interviews conducted revealed the following: 4 out of 5 staff support the allegation (S1, S2, S4, S5) while 1 out 5 staff were not aware due to working out in the rooms as a caregiver. 2 out of 8 residents were not interviewed due to their health condition (R1-R2). R3-R4 were no longer at the facility and as a result not interviewed. 3 out of 8 residents agreed (R5, R7, R8) while 1 out of 8 was informed but indicated that they did not report (R6). Interviews with staff (S1 and S2) indicated that Departmental agencies were not notified within 24 hours regarding scabies outbreak to Community Care Licensing (CDSS). Based on the evidence gathered, interviews conducted, and observations, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). Regarding the allegation, Facility did not have personal protective equipment for outbreak (PPE). Interviews conducted revealed the following: 1 out of 5 staff disagreed (S1) while 4 out of 5 staff agreed with the allegation (S2-S5). 2 out of 8 residents were not interviewed due to their health condition (R1-R2). R3-R4 were no longer at the facility and as a result not interviewed. 4 out of 8 residents agreed with the allegation (R5-R8). Observations revealed the following: The Department did not observe appropriate Personal Protective Equipment (PPE) in the facility. The Department interviewed witnesses 1 and #2 (W1-W2). (W2) verified to have been informed by the facility of (R2’s) scabies outbreak, however, was not aware of (R2) being restricted in the room. Furthermore, (W2) was not aware if (R2’s) primary physician was notified of (R2’s) condition. (W1) was not available for an interview and did not return the call. Based on the evidence gathered, interviews conducted, and observations, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D).
An exit interview, 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: 07/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4