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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320080
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:26:13 PM

Document Has Been Signed on 02/22/2024 02:26 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
02/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Suyono Wong (John), AdministratorTIME COMPLETED:
03:00 PM
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On 2/22/24 Licensing Program Analyst (LPA) Felisa Shirley conducted a Case Management visit to follow up on the death reported for Client #1 (C1). LPA was greeted by Claudia Lujon. LPA spoke with Claudia and explained the purpose of the visit was to gather information surrounding the death of (C1).

On 2/15/24, LPA Shirley received a copy of the death report from the facility staff who reported the death of (C1) on 2/15/24 at 5pm. The death report stated that approximately 5:00pm on 2/15/24 (C1) died of Cardiac failure. Byron was under the care of his physicians for cardio pulmonary care. John will email the following:


The following documents were requested:

· ID and Emergency Information,
· Admission Agreement
· Physicians Report
· Annual Physical
· Medications (MAR)

No deficiencies were cited during this visit.

An exit interview was conducted with Suyono Wong, (John) and a hard copy was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024
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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