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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 07/19/2026
Date Signed: 07/19/2026 03:24:27 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
06/11/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250611131031
FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:111CENSUS: 54DATE:
07/19/2026
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Cavin YooTIME COMPLETED:
03:29 PM
ALLEGATION(S):
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9
Facility retained resident with prohibited health condition.
INVESTIGATION FINDINGS:
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On July 19, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Cavin H. Yoo, Administrator, greeted the (LPA). (LPA) explained that the purpose of the visit was to deliver the findings for the allegation mentioned above.

The investigation consisted of the following: an initial visit on June 12, 25, and a subsequent visit on June 17, 2026. During the visits, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) , and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5 (S1-S5) and Residents #2-#6 (R2-R6), and Witness #2-#3 (W2-W3). (R1) and (W1) were not available for interviews.
(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
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 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

ALLEGATION #2: Facility retained resident with prohibited health condition.

It is alleged that the facility retained Resident #1 (R1) with a prohibited health condition. There are reports expressing concern about possible neglect in care for (R1), who has been a resident at this facility since 2018. It is reported that (R1) has a deep tissue injury to the sacrum that is unstageable, as well as an unstageable open ulcer on the right hip and a severe unstageable ulcer on the left foot, which exhibits sloughing tissue.

On May 8, 2025, Resident #1 (R1) was admitted to Cedars-Sinai Medical Center for a comprehensive evaluation and management of (R1's) health conditions. Upon admission, the medical team conducted a thorough wound assessment. The assessment revealed that (R1) suffered from a significant deep tissue injury located on (R1's) sacrum, which was classified as unstageable due to its severity and the absence of visible tissue layers. Additionally, (R1) presented with an open ulcer on (R1's) right hip, characterized by exposed underlying tissue and signs of infection. Furthermore, a severe ulcer was noted on (R1's) left foot, also unstageable, with sloughing tissues indicating advanced tissue damage and complicating factors that would require targeted intervention and careful monitoring throughout (R1's) treatment plan.

On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members acknowledged that (R1) was treated for pressure injuries. All staff members reported that (R1) had been a resident at Hayworth Terrace since 2018 and that (R1's)health continued to decline during this time, and (R1) has had ongoing pressure injuries "on and off" since being admitted to the facility. (R1) experienced frequent hospitalizations and was sent to skilled nursing in April 2025 due to pressure injuries, according to (S1). (S1) mentioned that (R1) was readmitted to the facility in late April 2025 at the request of (R1's) responsible party, who preferred (R1) to stay in an assisted living facility instead of skilled nursing.

(S1) also disclosed that when (R1) was readmitted in April 2025, (R1) had pressure injuries and was not under hospice care. Both (S1) reported that (R1) received services from Excellent Home Health and a Wound Rescue Specialist from April 18, 2025, until June 8, 2026, up to (R1's) passing on June 9, 2026.

(EVALUATION REPORT CONTINUES LIC 9009-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 10
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
06/11/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250611131031

FACILITY NAME:HAYWORTH TERRACEFACILITY NUMBER:
198320420
ADMINISTRATOR:ALDO CASESARIO APOSTOLFACILITY TYPE:
740
ADDRESS:325 N HAYWORTH AVETELEPHONE:
(323) 655-3101
CITY:LOS ANGELESSTATE:CAZIP CODE:
90048
CAPACITY:111CENSUS: 54DATE:
07/19/2026
UNANNOUNCEDTIME BEGAN:
12:33 PM
MET WITH:Cavin YooTIME COMPLETED:
03:29 PM
ALLEGATION(S):
1
2
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5
6
7
8
9
Questionable Death.
Resident's hygiene needs were not met by staff.
INVESTIGATION FINDINGS:
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On July 19, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Cavin H. Yoo, Administrator, greeted the (LPA). (LPA) explained that the purpose of the visit was to deliver the findings for the allegations mentioned above.

The investigation consisted of the following: an initial visit on June 12, 25, and a subsequent visit on June 17, 2026. During the visits, the department conducted a tour of the facility's physical plant and observed residents in care. The department obtained copies of the following documents: Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) , and other pertinent records associated with this complaint. Interviews conducted with Staff #1-#5 (S1-S5) and Residents #2-#6 (R2-R6), and Witness #2-#3 (W2-W3). (R1) and (W1) were not available for interviews.
(Evaluation Report continues LIC 9099-C)
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Questionable Death.

It is alleged that the death of Resident #1 (R1) is questionable. Reports indicate that (R1), who was bedbound and required assistance with activities of daily living, may have experienced neglect and a lack of proper care. (R1) was admitted to Cedars Sinai Medical Center dehydrated and with pressure injuries.

On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members could not corroborate this claim. All staff members claimed that (R1) had been a resident at the facility for a very long time since 2018 and that (R1’s) health continues to decline. (R1) was in and out of hospitals during (R1's) residency at Hayworth Terrace and was sent to skilled nursing in April 2025 and returned to the facility before (R1’s) passing, according to (S1). (S1) stated that (R1) had a history of respiratory failure with hypoxia. (S1-S2) reported that (R1) was being serviced by Excellent Home Health and Wound Rescue Specialist effective April 18, 2025, until June 08, 2026, when (R1) was admitted to Cedars Sinai Hospital. While the facility staff addressed (R1's) assisted daily living activities daily.

Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned.

The Department reviewed (R1’s) County of Los Angeles Department of Public Health Certificate of Death (dated 07/25/25) indicated (R1’s) death was an immediate cause of Acute Hypoxemic Respiratory Failure with underlying cause of Septic shock, pneumonia, and Alzheimer’s Dementia. Further review of (R1’s) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25).

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

(EVALUATION REPORT CONTINUES LIC 9009-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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Allegation #3: Resident's hygiene needs were not met by staff.

It is alleged that Resident #1 (R1’s) hygiene needs were not met by staff. Reports indicate that (R1) was bedbound and required assistance with all hygiene needs such as toilet and incontinence care, medication administration, feeding, grooming and bathing. Reports indicate that (R1) was unclean and dehydrated.

On June 17, 2026, and June 22, 2026, between 10:37 AM and 04:10 PM, the Department interviewed staff members identified as Staff #1 through Staff #5. Five (5) out of the five (5) staff members could not corroborate this claim. All staff members claimed that (R1) were being assisted adequately with hygiene care needs. (S2) stated there were no issues with (R1’s) medications and was being administered as prescribed by (R1's) primary physician. (S3-S5) reported that (R1) was being assisted with reposition, incontinence, hygiene and was given sponge bath once or twice a week. (S2-S5) claimed that (R1) was provided with liquids with every meal three times a day and as needed to stay hydrated. However, the facility staff did not maintain progress notes as part of the (R1’s) record or care documentation.

On June 17, 2026, between 01:11 AM and 03:29 PM the Department interviewed residents identified as Resident #2 through #6 (R2-R6). Five (5) out of the five (5) resident members could not support this claim. (R2-R6) reported that their hygiene needs are consistently met satisfactorily by the staff, expressing no concerns regarding this aspect of care. Additionally, they all indicated that they receive adequate meals and hydration throughout the day, with none experiencing dehydration due to a lack of available liquids from the facility.

Resident #1 (R1) was unavailable for an interview as resident had passed.

On June 30, 2026, July 02, 2026, and July 06, 2026, between 8:30 AM and 03:27 PM, the Department interviewed the witness members identified as Witness #2 and Witness #3. Two (2) out of the two (2) witnesses could not support this claim. During wound care visits, it was consistently noted that the (R1) maintained a satisfactory level of hygiene and did not show signs of neglect in this area according to (W2 and W3).

(EVALUATION REPORT CONTINUES LIC 9009-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned.

A review of Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25), and Death Report LIC 624A (dated 06/12/25).

Based on the information gathered, there is not enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.

An exit interview was conducted with Cavin H Yoo, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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Excellent Home Health and the Wound Rescue Specialist coordinated their efforts, with the Wound Rescue Specialist visiting (R1) once a week. . According to (S2-S5), the staff is trained to reposition residents every two to three hours and provide hygiene and incontinence care. However, (S1) also mentioned that staff do not receive assistance with wound care, as this is left to the Wound Rescue Specialist and Excellent Home Health.

(S2) stated that they are responsible for training the staff to spot pressure injuries. (S2) instructs the staff to look for signs, such as redness or blisters, on the skin before an open wound. If staff see these symptoms, they must inform the administrator. The administrator will then contact the primary physician and family representatives to obtain a referral for home health or hospice services.

Additionally, (S1) could not provide any documentation from Excellent Home Health or Wound Rescue Specialist, incident reports, or wound care related to (R1's) pressure injuries. As a result, (R1) continues to experience pressure injuries due to poor circulation, having been bedbound.

On June 30, 2025, July 02, 2026, and July 06, 2026, between 8:30 AM and 03:27 PM, the Department interviewed the witness members identified as Witness #2 and Witness #3. Two out of two witnesses confirmed this claim. During weekly wound care visits (W2 and W3), treatment was provided for (R1), who had pressure injuries classified as Stage 3, Stage 4, and unstageable, which are prohibited health conditions.

Witness #1 identified the party responsible for (R1) as not available for an interview, as telephone calls were not returned.

The Department reviewed the following records: Wound Rescue Special Records (dated 06/05/25). Notably, (R1) was assessed for (7) prohibited health conditions out of (17) wounds.

· Wound 1 and 2: Left Foot Lateral - Stage 4 (8 cm x 4 cm x 0.4 cm) Total wound size: 32 cm

· Wound 3: Left Foot Lateral – Stage 2 (0.5 cm x .05 cm x 0 cm) Total wound size: 0.25

· Wound 4: Left Foot Heel to Medial – Stage 4 (11 cm x 14 cm x 0.3 cm) Total wound size: 154 cm

· Wound 5, 6 and 7: Right Foot Lateral Stage 1 (cm x cm x cm) Total wound size: cm2

(EVALUATION REPORT CONTINUES LIC 9009-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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· Wound 8: Right Hip – Stage 3 (3 cm x 3 cm x 0) total wound size: 9 cm2

· Wound 9: Sacrum – Stage 3 (9 cm x 10 cm x 0.3 cm) Total wound size: 90 cm2

· Wound 10: Right Buttock #1 – Stage 3 (6 cm x 5 cm x 0.3 cm) Total wound size: 30 cm2

· Wound 11 Right Buttock #2 – Stage 2 (1 cm x 1 cm x 0 cm) Total wound size: 1 cm

· Wound 12: Right Buttock #3 – Stage 2 (3 cm x 2 cm x 0 cm) Total wound size: 6 cm2

· Wound 13: Back #1 – Stage 2 – (.05 c, x 0.5 c, x 0 cm) Total wound size: 0.25 cm2

· Wound 14: Back #2 – Stage 2 – (1 cm x 1 cm x 0 cm) Total wound size: 1 cm

· Wound 15: Right Leg – Stage 2 – (1 cm x 5 cm x 0 cm) Total wound size: 5 cm2

· Wound 16 – Left Foot – Unstageable – (1 cm x 1 cm x 0 cm) Total wound size: 1 cm2

· Wound 17 – Left Foot 5th - Unstageable – (1 cm x 1 cm x 0 cm) total wound size: 1 cm2

A review of Personnel Report LIC 500 (dated 05/27/26), Resident Roster (dated 06/17/26), Resident #1 (R1's) Face Sheet, Identification and Emergency Information LIC 601 (dated 01/24/18 & 05/13/21) Admission Agreement (dated 01/24/18), Appraisal/Needs and Services Plan LIC 625 (dated 05/25/23) Medical Assessment for Residential Care Facilities for the Elderly LIC 602A (dated 05/27/25), Consent Log (dated 05/25/23 & 07/15/23), Unusual Incident Report LIC 624 (dated 10/24/24 & 03/07/25), and Death Report LIC 624A (dated 06/12/25). Further review of the Facility Program Description "Plan of Operation" Section B under Prohibited Health Conditions: "No resident shall be admitted or retained in a residential care facility with a prohibited health condition.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

(EVALUATION REPORT CONTINUES LIC 9009-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
NARRATIVE
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California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted with Cavin H Yoo, and copies of the reports and appeal rights were provided.

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 11-AS-20250611131031
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: 07/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2026
Section Cited
CCR
87615(a)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including but not limited to... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.
This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22, Section 87615, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on pressure injuries and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 07/20/26.
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Based on interviews, observation, and record reviews, Licensee was aware of (R1's) pressure injuries upon readmission from SNF, retaining (R1) with (7) out of (17) wounds classified as Stage 3, Stage 4, or unstageable, which are prohibited health conditions. This violation poses an immediate health and safety risk to residents in care.
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Type B
07/20/2026
Section Cited
CCR
87208(a)
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87208 Plan of Operation(a) The licensee shall... operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49...

This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22, Section 87208, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on subject matter prohibited health conditions and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 07/31/26.
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Based on interviews, observations, and record reviews, the licensee was aware of (R1's) history of stage 3 and 4 pressure injuries and continued to retain (R1) despite the prohibition on health. This violation poses a potential health and safety risk to residents 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2026
LIC9099 (FAS) - (06/04)
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