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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 12/07/2023
Date Signed: 04/15/2024 12:30:51 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2023 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20231130085049
FACILITY NAME:164TH PLACE, INC.FACILITY NUMBER:
198320080
ADMINISTRATOR:NGUYEN, HAIFACILITY TYPE:
735
ADDRESS:1249 W.164TH STREETTELEPHONE:
(310) 714-6537
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:4CENSUS: 3DATE:
12/07/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joy Suarez, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
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9
Staff is sleeping in the garage
Staff showers in residents bathroom
INVESTIGATION FINDINGS:
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13
*This report serves as an amendment to clarify findings. It supersedes the complaint investigation findings reflected on report created 12/7/2023.

On 12/7/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA spoke to Administrator Joy Suarez and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following: On 12/7/23 LPA reviewed Resident files and interviewed both facility staff and residents. LPA reviewed and requested copies of the following records: Staff and residents files, tour of the facility, backyard and garage.

The investigation revealed the following:

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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-20231130085049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: 164TH PLACE, INC.
FACILITY NUMBER: 198320080
VISIT DATE: 12/07/2023
NARRATIVE
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Allegation: Staff is sleeping in the garage

It is being reported that staff is sleeping in the garage. LPA Shirley and Administrator Mariel toured the facility, backyard, office/activity room and the garage. While touring the backyard, LPA Shirley and Mariel observed the garage was being used for storage and observed several boxes, an old washing machine. LPA did not observe that anyone was sleeping in the garage. LPA Shirley interviewed staff S-1 through S-5 (S-1 – S-5), LPA ask them if they knew if anyone was sleeping at the facility or in the garage. Of those interviewed 5 out of 5 answered no. LPA Shirley interviewed one resident, (R-1). LPA ask if staff sleeps in their room, facility or the garage. The resident replied no. R2 and R3 were not available. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.



Allegation: Staff showers in residents bathroom

It is being reported that a member of staff is showering in the residents bathroom. LPA toured the facility with Mariel. LPA did not observe any personal items other than the residents items that live in the facility. During interviews, LPA interviewed S1 – S5(S1-S5). LPA ask, do you shower at this facility. Of those interviewed, 5 out of 5 answered, no. LPA Shirley interviewed one resident, (R-1). LPA ask does any staff members take showers here. The resident replied no. R2 and R3 were not available. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
An exit interview was conducted and a copy of this report was signed and provided to Administrator Mariel Ventura
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2023 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20231130085049

FACILITY NAME:164TH PLACE, INC.FACILITY NUMBER:
198320080
ADMINISTRATOR:NGUYEN, HAIFACILITY TYPE:
735
ADDRESS:1249 W.164TH STREETTELEPHONE:
(310) 714-6537
CITY:GARDENASTATE: CAZIP CODE:
90247
CAPACITY:4CENSUS: 3DATE:
12/07/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Joy Suarez, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff showers in residents bathroom
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Allegation: Staff showers in residents bathroom

It is being reported that the staff showers in residents bathroom. LPA Shirley toured the facility and interviewed staff S-1 through S-5 (S-1 – S-5), and ask them does anyone shower at the facility besides the residents. Of those interviewed 5 out of 5 answered no. LPA Shirley interviewed one resident, (R-1). LPA ask if anyone besides the residents shower at the facility. The resident replied no.

Based on interviews there is insufficient evidence to support the allegation staff showers in residents bathroom. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the report was given to the administrator, Suyono Wong.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20231130085049
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: 164TH PLACE, INC.
FACILITY NUMBER: 198320080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
CCR
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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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4