198320080-12-22-2021-11-AS-MVAO-CC4RLV-20220301120748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 12/22/2021
Date Signed: 12/22/2021 04:31:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20211216140231

FACILITY NAME:	164TH PLACE, INC.		FACILITY NUMBER:	198320080
ADMINISTRATOR:	NGUYEN, HAI		FACILITY TYPE:	735
ADDRESS:	1249 W.164TH STREET		TELEPHONE:	(310) 714-6537
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	4	CENSUS: 4	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Linda Whitford/Anne Gray		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident was physically assaulted by another resident in care.
Staff did not assist resident with bathing as needed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced complaint investigation at above facility. LPA called Linda Whitford, administrator, to conduct risk assessment. Per administrator Whitford, no one in facility has Covid-19 or any of the symptoms. LPA arrived at the facility and was greeted by staff. LPA explained purpose of visit is to investigate the allegations listed above and was allowed entry to the facility.

The investigation consisted of the following: On 12/22/2021 LPA Cifuentes met with Administrator, completed a walkthrough of facility and interviewed Client 1 – Client 4 (C1-C4) as well as Staff 1 -Staff 5(S1-S5). LPA also reviewed facility files and requested copies of register of facility residents, staff roster and other documents in association with the allegations.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211216140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: 164TH PLACE, INC.	FACILITY NUMBER: 198320080
	VISIT DATE: 12/22/2021

NARRATIVE

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RP alleges that it is unknown the last time C1 bathed and that staff do not assist C1 with bathing. LPA Cifuentes spoke with Administrator Linda Whitford regarding allegation. Mrs. Whitford stated all residents are bathed daily, sometimes at least three times a day. Most residents need assistance with ADL’s, but one needs less assistance since they are independent. LPA reviewed ISP for C1.Per ISP, C1 is able to self-care but prefers to have assistance with many tasks they are able to do with complete independence. When encouraged to bathe, toilet, and dress on own by staff, C1 exhibits aggressive behavior. LPA spoke with staff S1-S5 regarding allegation. 5 out of 5 staff interviewed stated clients are assisted with bathing. A few added that for more independent clients, they set-up bathing items and stand by in case there is a need for more assistance. Additionally, one of the staff stated that C1 had been bathed the day before and would be bathed today. LPA Cifuentes attempted to interview C2-C4, but due to client’s diagnosis’, interviews could not be completed. Of the clients who could be interviewed, 1 out of 1 stated staff stood nearby when they showered but offered verbal prompting in completing task .Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of records, and interviews conducted and found no evidence to support the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to administrator Anne Gray.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211216140231

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: 164TH PLACE, INC.	FACILITY NUMBER: 198320080
	VISIT DATE: 12/22/2021

NARRATIVE

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Investigation revealed the following:

Allegation: Resident was physically assaulted by another resident in care.

RP alleges C2 grabbed C1 by the hair and dragged them out of bed and across the room on 12/11/2021. LPA interviewed C1 who states C2 attacked them twice. C1 states the first time occurred in November 2021, C2 grabbed them by the hair and pulled them out of bed. C2 told LPA that in June 2021, C2 wanted C1’s apples and C2 grabbed the apples then grabbed C1 and threw them on the floor. Per C1 staff did not observe incident initially, appearing when C1 called. LPA interviewed Administrator Linda Whitford who states that in June 2021 C2 did enter C1’s room. While there, C2 tried to lift C1 by shoulders, but C2 did not grab C1 by hair and pull them out of bed. Staff immediately entered room and pulled C2 away. C2 is known to take people by the hand or shoulder and try to lead them out of facility. It is not a touch done to hurt anyone, it is C2’s method of communication. Facility records were reviewed by LPA. ISP for C1 notes that dishonest communication is a known behavior for C1 and episodes occur 2-3 times a day. ISP for C2 does not note grabbing as a noted behavior, but C2’s face sheet does note that C2 will grab staff by the arm and pull them to a noted area of interest. LPA spoke with staff S1-S5 regarding allegation. S1 stated that they observed C2 try and take apples from C1. C2 did not make physical contact with C1, they only grabbed for the apples. Of the other four staff interviewed, all four stated they had not seen C2 physically assault C1. LPA Cifuentes attempted to interview C2-C4, but due to client’s diagnosis’, interviews could not be completed. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Allegation: Staff did not assist resident with bathing as needed.

Continued on 9099-C.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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