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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 09/11/2026
Date Signed: 09/11/2026 02:22:10 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 Bernadette Allen
COMPLAINT CONTROL NUMBER: 11-AS-20260520113717
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: 45DATE:
09/11/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Hayworth Properties LLCTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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On 9/11/2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Bernadette Allen concluded this complaint investigation. On August 12, 2026, (CCLD) issued a Temporary Suspension Order (TSO). (TSO) temporarily suspends a facility’s license. Therefore, the Licensee Representative, Mohsen Abdosalehi, is served with this complaint investigation report through USPS Certified Mail 7018 1830 0000 6864 7443.

The Investigation consisted of the following:

On 5/27/2026 at 4:00 PM, the Department requested the staff and client roster, along with files for Residents 1–7 (R1–R7), by email, to be submitted by the close of business on 5/28/2026. The requested documentation included the admissions agreement, face sheet/emergency contact information, preplacement appraisal, needs and services plan, and physician’s report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
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-20260520113717
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: 09/11/2026
NARRATIVE
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 On 5/28/2026, the Department received the requested documentation for Residents 1–7.

The investigation revealed the following:

Allegation: Personal Rights

On 6/11/2026, the Department conducted interviews with Staff Members 1–6 (S1–S6) and attempted to interview Residents 1–2 (R1–R2). Resident 1 (R1) was not present at the facility during the investigation, and Resident 2 (R2) was not willing to participate. The Department successfully interviewed Residents 3–10 (R3–R10).

During the staff interviews, S1–S6 were asked whether they had observed any resident being yelled at, physically abused, handled in a rough manner, or spoken to in an inappropriate way by any staff member. 1 out of 6 staff members reported witnessing a resident being physically abused, including being slapped in the face and handled roughly by having their wrist held to restrain them in their wheelchair.

Staff Members S2–S6 stated they had not observed residents being physically abused, including being slapped in the face or handled roughly by having their wrist held to restrain them in their wheelchair. However, 4 out of 6 staff stated they had heard residents being yelled at by facility staff.

On 6/11/2026, Residents R3–R10 were asked whether they had been physically or verbally abused in any way, including being slapped in the face or handled roughly by having their wrist held to restrain them in their wheelchair. Of those interviewed, 8 out 10 reported that they had not been physically or verbally abused by any staff members.

On 8/6/2026, the Department was successful with conducted an interview with Resident 1 (R1), who was asked whether they had been yelled at, physically abused, handled in a rough manner, or spoken to in an inappropriate way by any staff member, including the reported incident involving being slapped in the face or having their wrist held to restrain them in their wheelchair. R1 stated they could not remember. The Department repeated the question, and R1 again stated they could not remember.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260520113717
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: 09/11/2026
NARRATIVE
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During the investigation the department did not observe or hear any staff member yelling or being physically or verbally abusive toward the residents in care.

Based on interviews conducted and records reviewed 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 and Chapter 8 are being cited on the attached LIC 9099D.


Copies of the reports were sent to Licensee Representative Mohsen Abdosalehi via USPS mail and electronic mail.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260520113717
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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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The licensee will conduct mandatory in service training for all staff members on Residents’ Personal Rights, including abuse prevention, respectful communication, and appropriate staff–resident interactions. This training will include a review of Title 22, Section 87468.1(a)(3) to ensure full comprehension of the resident’s rights. All staff will sign a Statement of Understanding confirming they have received the training, understand the cited regulation, and agree to comply with all requirements related to Residents’ Personal Rights. The licensee will submit proof of completion by the POC date of 09/12/2026 via email to Bernadette.Allen@dss.ca.gov.
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This requirement was not met as evidenced by: Baqsed on interviews conducted on 6/11/2026 with staff members 4 out of 6 staff stated they had heard residents being yelled at by facility staff which poses an immediate 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4