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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:51:53 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
12/21/2023 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:
02/08/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mariel Ventura TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Licensee does not ensure that facility documentation regarding residents is maintained adequately.
Staff slap resident(s) in care.
Staff yell at resident(s) in care.
INVESTIGATION FINDINGS:
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On 02/08/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent complaint visit regarding the allegation(s) above. LPA met with Administrator Mariel Ventura as the purpose of today’s visit was explained.

The investigation consisted of the following: On 02/08/24 LPA Villegas conducted a file review of daily living/ADLs log, file review for R1-R4, conducted a tour of the facility for a health and safety check and obtained a staff and resident roster.

The investigation revealed the following:
Licensee does not ensure that facility documentation regarding residents is maintained adequately. It is being alleged licensee does not ensure that facility documentation regarding residents is maintaine adequately. On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation stating that all staff are required and are producing daily signatures to track all residents daily
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 3
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: 02/08/2024
NARRATIVE
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living. On 12/28/23 LPA interviewed S1-S3 about the above allegation, 3 of 3 staff interviewed denied the allegation above and reported that if a signature is missed, staff are asked to return to the facility to sign the document. On 02/06/24 LPA interviewed to responsible parties for R1-R3 whom did not have any concerns to report. On 02/06/24 LPA was unable to interview responsible party for R4, LPA left a detailed voicemail with callback information. On 02/08/24 LPA conducted a file review of daily living/ADLs log and observed staff signatures were produced on documents. On 02/08/24 LPA conducted a file review for R1-R4 and observed all required documents to be in residents files. On 02/08/24 LPA spoke Westside Regional Center (W2) who provided updated IPP's for R1-R3.

The investigation revealed the following: Staff slap resident(s) in care. It is being alleged staff slap resident(s) in care. 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation reporting all staff treat all residents with respect and dignity. On 12/28/23 LPA interviewed S1-S3 about the above allegation, 3 of 3 staff interviewed denied the allegation above and stated they have great interactions with residents and treat the residents well. On 02/06/24 LPA interviewed to responsible parties for R1-R3 whom did not have any concerns to report. On 02/06/24 LPA was unable to interview responsible party for R4, LPA left a detailed voicemail with callback information. On 12/28/24 and 02/08/24 LPA did not observe and immediate health and safety concerns, LPA observed residents being attended too.

The investigation revealed the following: Staff yell at resident(s) in care. It is being alleged Staff yell at resident(s) in care. On 12/28/23 LPA interviewed Administrator (A1) regarding the above allegations, A1 denied the allegation stating that all staff do not yell at the residents but speak loudly and close to residents ears in order for communication to be effective. On 12/28/23 LPA interviewed S1-S3 about the above allegation, 3 of 3 staff interviewed denied the allegation above and reported that staff does not yell at the residents but staff has to speak loudly and staff has to repeat their statements multiple times in order for residents to comprehend. On 02/06/24 LPA interviewed to responsible parties for R1-R3 whom did not have any concerns to report. On 02/06/24 LPA was unable to interview responsible party for R4, LPA left a detailed voicemail with callback information. On 12/28/24 and 02/08/24 LPA observed staff speaking to residents in a calm yet loud tone, no immediate concerns were observed.

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: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3