Complaint·November 16, 2025

INVESTIGATION REVEALED THE FOLLOWING: Allegation #1: Staff had inappropriate interaction with resident. The complaint alleges that the staff interacted inappropriately with Resident #1 (R1). Reports indicate that a staff member engaged in inappropriate behavior when (R1) requested water. Specifically, it was reported that the staff member threw water in (R1's) face after only one day at the facility. No further information has been provided regarding this situation. On November 6, 2025, between 12:40 PM and 01:10 PM, the Department interviewed resident member identified as Resident #1 (R1). During the interview with (R1), several inconsistencies were noted in (R1’s) statements regarding the incident with Staff #1 (S1). (R1) initially stated that the incident occurred several weeks earlier, on October 8, 2025, before (R1's) admission to Hayworth Terrace on October 22, 2025. (R1) confirmed that the incident happened only once and expressed that (R1) perceived (S1's) behavior as inappropriate when (S1) threw water in (R1's) face. Additionally, (R1) expressed dissatisfaction with the facility, particularly regarding the incident with (S1). When asked about possible witnesses, (R1) pressed for more details but ultimately refused to provide additional information. On November 10, 2025, between 10:30 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of the five (5) resident members were unable to support this claim. (R2-R6) provided positive feedback about the staff, noting their professionalism in interactions. They all reported interacting with Staff #1 (S1), who was described as reliable, dependable, and proficient. On November 10, 2025, between 10:30 AM and 04:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members were able to validate the incident between Resident #1 (R1) and Staff #1 (S1). It was confirmed by (S1-S5) that no staff members misbehaved towards residents in care. (S2-S3) verified that (R1) was a patient at Martin Luther King, Jr. Community Hospital and was transferred to Hayworth Terrace on October 22, 2025. According to (S2), (R1) was at the facility for only one night when (R1) called 9-1-1 and was subsequently admitted to Cedar Sinai Hospital later that day, October 23, 2025, and did not have further information to disclose regarding (R1). (Evaluation Report continues LIC 9099-C) (S1) denied making any inappropriate remarks or exhibiting poor behavior toward (R1). (S1) asserted that (S1) did not throw water at (R1), emphasizing that this accusation is entirely unfounded. (S1) explained that (R1) was upset and wanted to leave the facility after staying at Martin Luther King, Jr. Community Hospital on October 22, 2025. In a moment of high emotion, (R1) threatened to call 9-1-1 and strongly objected to staying at Hayworth Terrace. The Department made several attempts to contact (R1's) family representative, Witness #1 (W1), but the calls went unanswered. The Department reviewed medical records from Martin Luther King, Jr. Community Hospital (dated 10/22/25), and the Unusual Incident Report (LIC 624) (dated 11/10/25) along with Centrally Stored Medication and Destruction Record LIC 622 (dated 10/22/25). The records show that (15) medications are prescribed, with (11) of these causing side effects such as confusion, agitation, depression, restlessness, dizziness, and vision or memory impairment (ref: National Institutes of Health). The medical records presented (R1) with a history of challenging situation faced with incidents involving a staff member at board and care facilities. Additional review of Staff Training revealed all staff have completed training in topics in Resident’s Rights, Abuse & Neglect, House Rules, Positive Behavior Support, and Positive Case Support. During the investigation on November 10, 2025, the Department observed staff members interacting with residents and noted that their conduct was appropriate. The Department found that the facility upholds the rights of its residents. Posters detailing Resident Rights, Personal Rights, and the California Residential Care Facilities for the Elderly Complaint Poster were displayed prominently throughout the facility. Based on the information gathered, there is not enough evidence to support the allegation mentioned above. Allegation #2: Staff did not provide resident with assistance in a timely manner. Allegation #3: Staff did not meet resident's needs while in care. The complaint claims that the staff did not promptly assist Resident #1 (R1) or meet (R1's) needs while in care. Reports indicate that (R1) received incontinence care only two hours later and that staff also failed to reposition (R1) as needed. No further information has been provided regarding this situation. (Evaluation Report continues LIC 9099-C) On November 6, 2025, between 12:40 PM and 01:10 PM, the Department interviewed resident member identified as Resident #1 (R1). During the interview with (R1), the Department noticed some inconsistencies in (R1's) account of the incident involving Staff #1 (S1). (R1) shared that the incident took place on October 8, 2025, before (R1) was admitted to Hayworth Terrace on October 22, 2025. (R1) expressed the challenges of being bed-bound and needing assistance with repositioning and diaper changes while under hospice care. (R1) felt that (S1) refused to help and purposely delayed assisting (R1) with these essential needs. When asked for more details, (R1) chose to end the discussion. On November 10, 2025, between 10:30 AM and 11:45 AM, the Department interviewed resident members identified as Resident #2 through Resident #6 (R2-R6). Five (5) out of the five (5) resident members could not corroborate these claims. (R2-R6) provided affirmative feedback regarding the staff's responsiveness to their care and needs. They reported multiple interactions with (S1), during which assistance was consistently prompt and their individual needs were effectively addressed. On November 10, 2025, between 10:30 AM and 04:59 PM, the Department interviewed staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff members were able to validate these claims between Resident #1 (R1) and Staff #1 (S2-S3) verified that (R1) was a patient at Martin Luther King, Jr. Community Hospital and was transferred to Hayworth Terrace on October 22, 2025, and was on under hospice care with Comforter Hospice. According to (S2), (R1) was at the facility for only one night when (R1) who contacted 9-1-1 and wanted to be off hospice care. (S2-S3) stated (R1) was released from (MLK) hospital at 5:30 PM and was sent over to our facility and was admitted at Hayworth Terrace approximately at 7:00 PM. (R1) was in a private room overnight and the facility did not really abundance of time to fully attend to (R1’s) needs as (R1) admitted self to Cedar’s Sinai by contacting 9-1-1 the less than 24 hours. In an interview, (S1) denied the allegations, saying they are not true. (S1) mentioned that (R1) was resentful and did not want to receive hospice care. (R1) threatened to call 9-1-1 and was firmly against staying at Hayworth Terrace. According to (S1), (R1) had (R1's) diapers changed twice during the evening and was repositioned twice before paramedics took (R1) to Cedar Sinai Hospital on October 23, 2025. The Department made several attempts to contact (R1's) family representative, Witness #1 (W1), but the calls went unanswered. (Evaluation Report continues LIC 9099-C) The Department reviewed medical records from Martin Luther King, Jr. Community Hospital (dated 10/22/25), and the Unusual Incident Report (LIC 624) (dated 11/10/25) along with Centrally Stored Medication and Destruction Record LIC 622 (dated 10/22/25). The records show that (15) medications are prescribed, with (11) of these causing side effects such as confusion, agitation, depression, restlessness, dizziness, and vision or memory impairment (ref: National Institutes of Health). The medical records presented (R1) with a history of challenging situation faced with incidents involving a staff member at board and care facilities. A review of all staff indicates that they have completed their training in the following areas: Basic Care, Health and Safety, Specialized Care, Dementia and Alzheimer’s Care, and Documentation and Reporting. Based on the information collected, there is not enough evidence to support the allegations 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 Yun Ji Kim and copies were provided.