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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:13:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20231221115047
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:
12/28/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mariel Ventura TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Uncleared adults are working at the facility.
Facility manager encourages staff to falsify documents regarding residents in care.
Staff are not following prescribed dietary restrictions for resident in care.
INVESTIGATION FINDINGS:
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On 12/28/23 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Administrator Mariel Ventura as the purpose of today’s visit was explained.

The investigation consisted of the following: On 12/28/23 LPA interviewed Administrator (A1), staff #1-3 (S1-S3), and resident # 1 (R1), LPA was unable to interview Residents #2-4 (R2-R4) due to communication barriers. On 12/28/23 LPA obtained copies of the staff and resident roster, background check clearance for all employees, DSP onsite orientation checklist, 4 hour job shadowing log, DSP qualifications form for staff #1-,2,4,5,6 and 7 and DSP 1 and DSP 2 verification form for A1, S2, S4, S7.

LPA obtained the following for R1-4; face sheet, physician’s report, medication list, and IPP from the Westside Regional Center.
The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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 5
Control Number 11-AS-20231221115047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/28/2023
NARRATIVE
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Allegation- Uncleared adults are working at the facility.

It is alleged uncleared adults are working at the facility. On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation above stating all employees have clearance and have documentation in their file. On 12/28/23 LPA Villegas reviewed the Licensing Information System & Guardian system and confirmed that all 8 employees on employee roster have active criminal record clearance. LPA did not observe any other individuals working in the facility at the time of the visit.

Allegation: Facility manager encourages staff to falsify documents regarding residents in care.

It is alleged Facility manager encourages staff to falsify documents regarding residents in care. On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation. Per A1 If a signature is missed, staff will be called back to the facility to provide signature(s) required, A1 continued to report that has been no alteration nor updates made on resident records/forms. On 12/28/23 LPA interviewed S1-S3 about the above allegation, 3 of 3 staff interviewed reported that if a signature is missed, staff are asked to return to the facility to sign the document. On 12/28/23 LPA verified signatures on MAR with S1 and S1 confirmed S1 provided signatures produced.

Allegation: Staff are not following prescribed dietary restrictions for resident in care.

It is being alleged that Staff are not following prescribed dietary restrictions for resident in care. On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation above reporting that no resident has a dietary restriction. Per A1, there is a resident with a shrimp allergy and therefore the facility does not provide shrimp at all. On 12/28/23 LPA interviewed S1-S3 regarding the above allegation, 3 out of 3 staff interviewed denied the allegation. On 12/28/23 LPA conducted a review of R1’s IPP which states that R1 has a regular chopped diet. R2-R4 IPP’s state R1-R4 have regular diets.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Exit interview conducted with Administrator Mariel Ventura, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/21/2023 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20231221115047

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:
12/28/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mariel Ventura TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Untrained staff working at the facility.
INVESTIGATION FINDINGS:
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On 12/28/23 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted an initial complaint visit regarding the allegations above. LPA met with Administrator Mariel Ventura as the purpose of today’s visit was explained.

The investigation consisted of the following: On 12/28/23 LPA interviewed Administrator (A1), staff #1-3 (S1-S3), and resident # 1 (R1), LPA was unable to interview Residents #2-4 (R2-R4) due to communication barriers. On 12/28/23 LPA obtained copies of the staff and resident roster and the following for R1-R4; facesheet, physician’s report, medication list, and IPP from the Westside Regional Center.
The investigation revealed the following:

Allegation- Untrained staff are working at the facility.
It is alleged untrained staff that are administering medications and also that staff do not have DSP 1 & DSP 2 training.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
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 5
Control Number 11-AS-20231221115047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/28/2023
NARRATIVE
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On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation. Per A1, only S1, S2 and A1 administer medication as DSP training has been obtained. A1 continued to state that medication training is done by facility nurse once a month. On 12/28/23 LPA interviewed S1-S3 about the above allegation, 3 out of 3 staff denied the allegation above allegation. On 12/28/23 LPA conducted a review of personnel files for S1-S8 to determine if all staff have all required training in accordance with the approved plan of operations on file at the Licensing office and title 22 regulations. LPA observed DSP 1 and DSP 2 verification form for A1, S2, S4, S7. 1 of 6 staff does not have DSP 2 training and has been employed since October 2020, 1 of 7 staff does not have neither DSP 1 nor DSP 2 training and has been employed since November 2020.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator Mariel Ventura, appeal rights explained, and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20231221115047
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
01/11/2024
Section Cited
CCR
80026(a)(b)(6)
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Each licensee shall have and maintain on file a current, written, definitive plan of operation.The plan and related materials shall contain the following: Plan for inservice education of staff if required by regulations governing the specific facility category.
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Administrator will enroll 2 staff in DSP training and will submit proof of training completion by POC due date in order to be in complaince with approved plan of operation.
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LPA reviewed the facilitys approved plan of operation which indicatedall staff are required to have DSP 1 and DSP 2 training. Based on LPAs records review 1 or 7 staff did not have DSP 2 training and 1 of 7 staff did not have DSP 1 or DSP 2 training.
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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: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5