Other·April 9, 2020

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health of a Complaint investigation during an Abbreviated Standard Survey. Complaint number: CA00677308 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 33483 The inspection was limited to the specific Complaint investigation and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for CA00677308 The Department declared an Immediate Jeopardy (IJ) on 2/20/20 at 4:24 p.m. The facility's Administrator, Director of Nursing (DON), and Dietary Services Supervisor (DSS) were notified of the immediacy and seriousness of the facility's non-compliance for 73 of 73 resident's health and safety. On 2/22/20 at 12:45 p.m., the IJ was lifted , after the team verfied the facility's Plan of Action (POA) was implemented through observation, interview, and record review.

F812 SS=K Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 07/14/2020 §483.60(i) Food safety requirements. The facility must LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 1 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to prepare and serve food for lunch in a sanitary kitchen environment when cockroaches were found in the kitchen during lunch preparation for 67 of 73 vulnerable residents. This failure placed the 67 vulnerable residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such cockroaches, mosquitos, ticks, and fleas), and had the potential for the 67 vulnerable residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On February 20, 2020 at 10:30 AM and at 1:57 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 2 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE PM, respectively, the Los Angeles County Department of Public Health Environmental Health Specialist (EHS, an environmental inspector who performs inspection of various facilities and properties to determine compliance with applicable State laws and County Ordinance Code sections) and the surveyor observed live cockroaches in the facility's kitchen. On February 20, 2020 at 4:24 PM, the Department declared an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment of death of a resident), and notified the facility's Administrator, Director of Nursing (DON), and Dietary Services Supervisor (DSS). On February 22, 2020 at 12:45 PM, the Department removed the IJ and notified the Administrator and the DON after verifying and confirming on-site that the facility had implemented the acceptable written plan of action as follows: 1. All residents that was served food (67 residents) for lunch will be monitored for any abdominal discomfort i.e., nausea, vomiting, diarrhea, abdominal pain and fever to start 2/20/20 at 3-11 x 72 hours. 2. If above sign and symptom is observed, the attending physician (MD) will be notified as well as responsible party immediately. 3. Emergency Resident Council Meeting will be held tomorrow 02/21/20 at 10am to inform residents at the facility regarding kitchen nonoperational use. 4. Identified food preparation alternative FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 3 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE location which is at the conference room. Registered Dietician spear heading the food preparation together with the Dietary Supervisor following the emergency menu. Sanitized the place. Facility is using disposable utensils/ dishes. Emergency menu is comprised of food that are readily served and does not need to be heated according to our policy. 5. Utilize emergency menu 6. Posted emergency menu Findings: During an entrance conference with the Administrator and the DON on February 20, 2020 at 12:37 PM, the DON said there were 73 in-house residents in the facility. There were six residents on gastric tube feeding (liquid food through a tube inserted to the stomach through the abdomen). During an interview with the EHS in the facility on February 20, 2020 at 12:48 PM, the EHS said she has observed five live and four dead German cockroaches (a small kind of cockroaches), and fecal spottings from the cockroaches. The EHS found the five live cockroaches under the steam table. The EHS found the four dead cockroaches under the dishwasher in the kitchen. During a tour to the kitchen with the EHS on February 20, 2020 at 12:53 PM, racks of finished lunch trays were found along the hallways. The surveyor observed directly the location where the live and dead cockroaches where found. There were two dead cockroaches and one empty casing (hatched egg which could contain 40 or more baby cockroaches) found under the dishwasher. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 4 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE There were no live cockroaches found. During an interview with the Dietary Services Supervisor (DSS) on February 20, 2020 at 1:22 PM, the DSS said the EHS banged on the dishwashing sink and pointed to the DSS the dead cockroaches found underneath the sink. The EHS also pointed to DSS the live cockroaches found under the steamtable. The DSS stated what the EHS pointed to her under the dishwasher and the steamtable sink. During an observation of the dry storage area with the DSS on February 20, 2020 at 1:39 PM, in between the salt tank for the water softener and the corner of the wall, the surveyor observed a black small egg-shaped object. When it was being swept out from that corner with a plastic broom, the egg shape object disintegrated. A black-brown liquid came out of the egg shape object with a stench originating from it. During an observation of the space between the reach-in freezer and the wall adjacent to the DSS's office on February 20, 2020 at 1:46 PM, one dead cockroach was found. During a concurrent re-observation and interview of the shelf under the steamtable, with Cook 1, on February 20, 2020 at 1:57 PM, a live cockroach [German cockroach] crawled out on the metal pipe from a hole on the shelf under the steamtable. The metal pipe came from under the floor through the hole on the shelf under the steamtable. Cook 1 stated one live was cockroach found on the metal pipe crawling out from the hole. Cook 1 raised her voice in surprise to confirm the live roach. During a further observation of the metal pipe under the steamtable on February 20, 2020 at 2:05 PM with Cook 1 and the Dietary Aide (DA) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 5 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1, DA 1 pointed a live cockroach crawling between the feet of the surveyor. The surveyor called the DSS to show the live cockroach. The DSS stepped on the live cockroach to crush it. During a follow up interview with the DSS on February 20, 2020 at 4:05 PM, the DSS said she met the EHS in the kitchen at around 10:30 AM. The EHS started banging on the sink near the dishwasher and found the cockroach problem. DSS stated when EHS informed her of the cockroach infestation, lunch was prepared and ready for tray line (serving the cooked food on trays for distribution to the residents). The DSS stated the cockroach infestation made the facility's kitchen unsanitary. The DSS stated the food prepared in the unsanitary kitchen was considered contaminated. The DSS further said she (DSS) still decided to serve the contaminated food for lunch for the 67 vulnerable residents. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation," retrieved on February 26, 2020 at http://publichealth.lacounty.gov/eh/docs/Special ized/Vector_Management/cockroachMgmt.pdf, indicated the cockroaches may become pests in a structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that love outdoors come into contact with human excrement in sewers or with per dropping, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Center for Disease Control and Prevention, Guidelines for Environmental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 6 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Infection Control in Health Care Facilities, updated on July 2019 and retrieved on February 26, 2020 at https://www.cdc.gov/infectioncontrol/guidelines/ environmental/index.html indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in healthcare facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as vector (carrier that transfer an infectious organism from one host to another).

F925 SS=L Maintains Effective Pest Control Program CFR(s): 483.90(i)(4)

F925 07/14/2020 §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to conduct an ongoing monitoring of the kitchen environment and review the pest control company's inspection report to ensure the kitchen is free from cockroaches (small insects that cause spread of bacterial infection) for 73 of 73 vulnerable (susceptible to physical or emotional attack or harm) residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 7 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure placed the 73 vulnerable residents at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects such cockroaches, mosquitos, ticks, and fleas), and had the potential for the 73 vulnerable residents to experience food infection from ingesting live bacteria, food intoxication from ingesting food containing toxins from bacteria, and disease transmission that can lead to life threatening complications and death. On February 20, 2020 at 10:30 AM and at 1:57 PM, respectively, the Los Angeles County Department of Public Health Environmental Health Specialist ([EHS] an environmental inspector who performs inspection of various facilities and properties to determine compliance with applicable State laws and County Ordinance Code sections) and the surveyor observed live cockroaches in the facility's kitchen. On February 20, 2020 at 4:24 PM, the Department declared an Immediate Jeopardy (IJ, a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment of death of a resident), and notified the facility's Administrator, Director of Nursing (DON), and Dietary Services Supervisor (DSS). On February 22, 2020 at 12:45 PM, the Department removed the IJ and notified the Administrator and the DON after verifying and confirming on-site that the facility had implemented the acceptable written plan of action as follows: 1. Kitchen kept closed and not used from February 20, 2020 at 12:30 PM. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 8 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. Trashed all opened and not sealed food found in the kitchen during the infestation. 3. Maintenance staff started deep cleaning the kitchen, which includes moving appliances and deep cleaning surfaces. 4. Called Pest Control Company and the company did pest control treatment in the kitchen starting on February 20, 2020 at 7:30 PM. 5. Identified food preparation alternative location was at the conference room. Registered Dietician spear heading the food preparation together with the Dietary Supervisor following the emergency menu. Sanitized the place. Using disposable utensils/ dishes. Emergency menu is comprised of food that were readily served and does not need to be heated according to our policy. 6. Utilized emergency menu during the kitchen closure. 7. Posted emergency menu during the kitchen closure. Findings: A review of the facility's census report, dated February 19, 2020, indicated there were 73 inhouse residents in the facility. During an interview with the EHS in the facility on February 20, 2020 at 12:48 PM, the EHS stated she has observed five live and four dead German cockroaches (a small kind of cockroaches), and fecal spotting from the cockroaches. The EHS found the four dead cockroaches under the dishwasher in the kitchen and five live cockroaches under the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 9 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE steam table. During a tour and an observation of the kitchen with the EHS on February 20, 2020 at 12:53 PM, there were two dead cockroaches and one empty casing (hatched egg which could contain 40 or more baby cockroaches) found under the dishwasher. During an interview with the Dietary Services Supervisor (DSS) on February 20, 2020 at 1:22 PM, the DSS said EHS banged on the dishwashing sink, and pointed to the DSS the dead cockroaches found underneath the sink and the live cockroaches found under the steamtable. During an observation of the dry storage area with the DSS on February 20, 2020 at 1:39 PM, in between the salt tank for the water softener and the corner of the wall, there was a black small egg-shaped object. When it was being swept out from that corner with a plastic broom, the egg shape object disintegrated. A blackbrown liquid came out of the egg shape object with a stench originating from it. During an observation of the space between the reach-in freezer and the wall adjacent to the DSS's office on February 20, 2020 at 1:46 PM, one dead cockroach was found. During a concurrent re-observation and interview of the shelf under the steamtable, with the cook (Cook 1), on February 20, 2020 at 1:57 PM, a live cockroach [German cockroach] crawled out on the metal pipe from a hole on the shelf under the steamtable. The metal pipe came from under the floor through the hole on the shelf under the steamtable. Cook 1 stated one live cockroach found on the metal pipe crawling out from the hole. Cook 1 raised her voice in surprise to confirm the live FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 10 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE roach. During a further observation of the metal pipe under the steamtable on February 20, 2020 at 2:05 PM with Cook 1 and the Dietary Aide (DA) 1, DA 1 pointed out a live cockroach crawling between the feet of the surveyor. The surveyor called the DSS to show the live cockroach. The DSS stepped on the live cockroach to crush it. During a review of the pest control company service report for the past 6 months, the following were indicated: On August 15, 2019 and timed at 7:15 PM (Order 21066) - roach infestation, product applied for all types of pests (a destructive insect or other animal that attacks crops, food, livestock, etc.); On August 22, 2019 and timed at 7:15 PM (Order 20897) - kitchen was serviced, product applied without targeted pests; On September 10, 2019 and timed at 7:31 PM (Order 21436) - German roach infestation, product was applied without targeted pests; On October 24, 2019 and timed at 7:14 PM (Order 21504 - kitchen was serviced, product applied without targeted pests; On January 2, 2020 and timed at 7:06 PM (Order 22285) - kitchen was serviced, product applied without targeted pests. During an interview with the Maintenance Supervisor (MS) on February 26, 2020 at 10:32 AM, the MS said he is responsible for the pest control in the facility including the kitchen. MS stated he received the pest control company service report and did not review the service reports received. MS added the service reports FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 11 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were important to know about the pest control issues in the facility, and to be able to treat the issue appropriately. MS also added the pest control company has not provided him and the facility of any pest control monthly assessment even the initial assessment for the facility. A review of an article from the Los Angeles County Department of Public Health titled, Effective Management of Cockroach Infestation," retrieved on February 26, 2020 at http://publichealth.lacounty.gov/eh/docs/Special ized/Vector_Management/cockroachMgmt.pdf, indicated the cockroaches may become pests in a structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that love outdoors come into contact with human excrement in sewers or with per dropping, they have the potential to transmit bacteria that cause food poisoning if they enter into structures. A review of the Center for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health Care Facilities, updated on July 2019 and retrieved on February 26, 2020 at https://www.cdc.gov/infectioncontrol/guidelines/ environmental/index.html indicated the guidelines were recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. Pest Control Included cockroaches found in healthcare facilities that can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as vector (carrier that transfer an infectious organism from one host FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 12 of 13 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555677 (X3) DATE SURVEY COMPLETED 03/12/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HAWTHORNE HEALTHCARE & WELLNESS CENTRE, LP 11630 Grevillea Ave Hawthorne, CA 90250 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to another). During a review of the facility's policy and procedure for Pest Control, revised January 1, 2012, indicated the facility maintains an ongoing pest control program to ensure the building and grounds were kept free of insects, rodents, and other pests. The Administrator arranges for pest control company to visit and inspect the facility once a year. The pest control company will carry out inspection, evaluation, submit, and carry kitchen was serviced, product applied without targeted pests; actions needed to rid the facility and its grounds of any environmental pests. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MMTC11 Facility ID: CA910000047 If continuation sheet 13 of 13