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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320420
Report Date: 09/02/2026
Date Signed: 09/02/2026 01:09:22 PM

Unsubstantiated


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
08/27/2026 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260827083750
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:
09/02/2026
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Cavin YooTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Questionable death.
Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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On September 2, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet 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 #70181830000068686422.

The investigation included a review of records, and an observation of the facility. The Department obtained several documents, including the Personnel Report LIC 500 (dated02/23/26), the Resident Roster (dated 08/27/26), service records for Resident #1 (R1) Incident Report LIC 602A (dated 08/27/26), Medical Assessment LIC 602A (dated 07/28/25), Face Sheet (dated 07/09/25), Appraisal/Needs and Service Plan LIC 625 (dated 07/29/25) and other pertinent records associated with this complaint. Interviews with Staff # 1-#4, Resident #2- #5 and Witness #1. Resident #1 was not available for an interview.
(Evaluaton Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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-20260827083750
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: 09/02/2026
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation #1: Questionable deaths.

It is alleged that staff neglect led to the deaths of residents. Reports indicated that staff neglect led to the deaths of some residents and that the system at Hayworth is unethical, with ongoing issues. No further details were available.

On August 27, 2026, between 10:45 AM and 2:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of the four (4) could not validate this claim. The interviews carried out did not reveal any proof suggesting that the facility staff showed negligence, failed to deliver sufficient care, or participated in actions that could have led to the reported deaths.

On August 27, 2026, between 01:00 PM and 2:30 PM, the Department interviewed residents identified as Resident #2 through Resident # 5 (R2-R5). Four (4) out of the four (4) could not support this claim. Residents interviewed all stated that they have not observed any suspicious or questionable deaths in the facility.

Resident #1 (R1) was not available for an interview as several telephone calls went unanswered.

On August 28, 2026, between 12:02 PM and 12:20 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) claimed to be unaware of (R1's) assertion regarding questionable or suspicious deaths, as (R1) has never raised any such issues.

The Department performed a review of resident records. It determined that the medical conditions of residents who were hospitalized in the last six months were accurately documented and aligned with their decline. Further review of records found that the facility provided standards in its documentation, reporting, and communication with medical professionals. No discrepancies were found.

There were no witness statements, documentation, or observations supported the allegation that the deaths were questionable or resulted from facility action or inaction.

Based on the information gathered, the Department was unable to establish that the facility violated any regulations or contributed to the residents’ questionable deaths.

(Evaluation Report continues LIC 9099-C)

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected in the report created on 09/02/26.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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-20260827083750
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: 09/02/2026
NARRATIVE
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Allegation #2: Staff did not safeguard resident's personal belongings.

It is alleged that staff did not safeguard Resident #1's (R1’s) personal belongings. Reports indicated that R1 experienced theft of personal belongings by the staff. However, no names of staff involved or additional details were provided.

On August 27, 2026, between 10:45 AM and 2:00 PM, the Department interviewed staff members identified as Staff #1 through Staff #4 (S1-S4). Four (4) out of the four (4) staff members could not corroborate this claim. Staff mentioned that they did not mishandle or remove (R1's) possessions and adhered to facility procedures for recording personal property. All personnel noted that residents retain access to their belongings unless arranged otherwise. Documentation met regulatory standards, with no discrepancies in inventory records or staff accounts. Staff outlined the facility's guidelines on resident property, emphasizing documentation and access control. (S1-S2) stated that (R1) has never reported any missing items to management.

On August 27, 2026, between 01:00 PM and 2:30 PM, the Department interviewed residents identified as Resident #2 through Resident # 5 (R2-R5). Four (4) out of the four (4) could not support this claim. Residents interviewed reported that they have not experienced any theft or loss of personal belongings. All residents confirmed that their room doors are locked and that the facility is secure against theft. Additionally, residents mentioned that it is their own responsibility to safeguard their personal items.

Resident #1 (R1) was not available for an interview as several telephone calls went unanswered.

On August 28, 2026, between 12:02 PM and 12:20 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) expressed uncertainty regarding whether any of (R1’s) personal items have been lost or taken, as (R1) has never indicated anything to that effect.

The Department reviewed (R1’s) Face Sheet (dated 07/09/25), Identification and Emergency Information LIC 601 (dated 07/09/25, Resident Information Form (dated 07/09/25), Medical Assessment LIC 602A (dated 07/28/25), Incident Report LIC 624 (dated 08/27/26), Appraisal/Needs and Services Plan LIC 625 (dated 07/29/25), Admission Agreement (dated 07/09/25), and Progress Notes (dated 074/29/25 through 08/17/26). A review of Resident Personal Property and Valuables LIC 621 (dated 07/09/25) showed that no personal items were documented.

(Evaluation Report continues LIC 9099-C)

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

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260827083750
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: 09/02/2026
NARRATIVE
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On August 27, 2026, the Department inspected (R1’s) room and observed that it appeared to be in orderly condition.

Based on the information gathered, the Department was unable to establish that staff violated regulations related to resident property or personal rights.

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.



No deficiencies cited.

Copies of the reports were sent to Licensee Representative Mohsen Abdosaleh via USPS mail and electronic mail.



This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected in the report created on 09/02/26.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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: 4 of 4