198320080-10-1-2024-11-AS-FSHY-D8SRZP-20240904132816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320080
Report Date: 09/04/2024
Date Signed: 10/01/2024 12:03:38 AM

Document Has Been Signed on 10/01/2024 12:03 AM - 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/ DIRECTOR:	NGUYEN, HAI		FACILITY TYPE:	735
ADDRESS:	1249 W.164TH STREET		TELEPHONE:	(310) 714-6537
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY: 4		CENSUS: 3	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:25 AM
MET WITH:	Mariel Ventura, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 09/4/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Mariel Ventura and explained the purpose of today’s visit. The facility is licensed to serve developmentally disabled residents 10 - 59 years, cleared for four (4) ambulatory residents, of which 2 maybe non-ambulatory.

LPA reviewed all resident files and found they contained the required documents. LPA reviewed five (5) staff files and found they contained the required documents, training, and certification. LPA reviewed the surety bond. LPA reviewed the training logs for staff. LPA received a copy of the Liability Insurance.

LPA Felisa and Mariel toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (4) client bedrooms, (1 1/2) bathroom, living room, kitchen, dining area, patio, garage used for storage. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 are occupied by residents and contain the mandated furniture. The fourth room contains items from resident who is moving out today. LPA observed all rooms to have the required furniture including a bed, dresser(s), nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Mariel toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medications were locked and stored in drawers in each of the resident’s rooms and inaccessible to the resident. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 118.7 degrees Fahrenheit.

Con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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
	VISIT DATE: 09/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The first bathroom has grab bars and is clean and is operational. First aid kit is fully stocked with manual. No firearms are stored at facility and no bodies of water present. This facility is in good repair.

LPA Shirley and Mariel walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, shaded patio area and there are no bodies of water present.

There were no deficiencies.

An exit interview was conducted, and a copy of this report was provided to Administrator, Mariel Ventura.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2