198320080-1-22-2024-11-AS-RORN-D3JNGQ-20240320102729

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 01/22/2024
Date Signed: 01/22/2024 10:57:19 AM

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
12/20/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231220082331

FACILITY NAME:	164TH PLACE, INC.		FACILITY NUMBER:	198320080
ADMINISTRATOR:	NGUYEN, HAI		FACILITY TYPE:	735
ADDRESS:	1249 W.164TH STREET		TELEPHONE:	(310) 714-6537
CITY:	GARDENA	STATE: CA	ZIP CODE:	90247
CAPACITY:	4	CENSUS: 4	DATE:	01/22/2024
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Criselda Gomez, Caregiver		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not reporting medication errors

INVESTIGATION FINDINGS:

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On 1/22/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by Mariel Ventura, Administrator, and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:

On 12/20/23 LPA reviewed resident files and toured the facility. LPA requested and received copies of the MAR logs. 1/22/24 LPA requested and received copies of staff roster, resident roster, trainings for staff that dispense medication.

The investigation revealed the following:

Cont'd 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231220082331

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: 01/22/2024

NARRATIVE

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Allegation: Staff are not reporting medication errors

It is being reported that there are many errors on reports and the staff are being told not to document the errors and not to write incident reports to CCLD. RP stated that staff has pictures as proof of mistake but refused to name staff. On 1/22/24 at LPA Shirley reviewed residents MAR’s. LPA observed there to be no mistakes or entries on the log. LPA reviewed training records for staff which are current. All staff interviewed deny that there are pictures of any mistakes.

On 1/22/24 LPA Shirley interviewed resident 1 (R-1). LPA asked, do you believe that staff are making errors with your medications. Resident answered no. R-2, R-3, and R-4 were not available for interview as they are non-verbal. On 1/22/24 LPA Shirley interviewed staff 1-staff 4 (S-1 - S-4). LPA asked staff, in regards to medication, if there is an error, are you reporting the medication error. Of those interviewed, 3 out 4 staff answered yes. S-3 does not dispense medication. S-5 was not available for interview.

Based on information gathered, the department did not find sufficient evidence to support allegations "Staff are not reporting medication errors” 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 LIC 9099 report was provided to Mariel Ventura, Administrator.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC9099 (FAS) - (06/04)

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