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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320080
Report Date: 09/23/2023
Date Signed: 09/23/2023 01:04:50 PM

Document Has Been Signed on 09/23/2023 01:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 4DATE:
09/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Mariel VenturaTIME COMPLETED:
01:15 PM
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On 9/23/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Administrator Mariel Ventura and Hai Nguyen and explained the purpose of today’s visit. The facility is licensed for 4 clients, 2 ambulatory, 2 non-ambulatory. Facility has a fire clearance for 2 ambulatory and 2 non-ambulatory.

The facility is a one-story home located in a residential neighborhood. The facility consists of the following: four (4) resident bedrooms, two (2) bathrooms, dining area, kitchen, living room, office area and shaded patio area in the backyard.

LPA and staff toured the physical plant. There were no obstructions on the premises or small bodies of water. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The hot water temperature tested at 115.9F degrees. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Five (6) smoke detectors were observed to be hardwired and interconnected. Facility has one fire extinguisher, fully charge.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Mariel Ventura.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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