<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 02/10/2024
Date Signed: 02/10/2024 12:08:21 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
04/04/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230404140605
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:
02/10/2024
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Jerome Alejo BusuegoTIME COMPLETED:
11:52 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident tested positive for Fentanyl due to staff neglect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/10/2024, Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by Direct Support Provider (S4:Jerome Alejo Busuego). The purpose for today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: On 04/05/23 LPA Perry Scott conducted an initial visit and met with Administrators (A1: Mariel Ventura) and (A2: Suyono Wong). During the visit, LPA conducted a tour of the facility’s physical plant and observed the clients in care. LPA obtained copies of the following documents: Clients Roster, Staff Roster, Administrator Certifications, personnel records, staff in-service training, and client’s records (MAR, ID/Emergency Info, Individual Program Plan (IPP)). This complaint was referred to California Department of Social Services Investigation Bureau for investigation and was assigned to Investigation Bureau Investigator (Christine Ferris).

(Evalutation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
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-20230404140605
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: 02/10/2024
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
As a part of the investigation Investigator Ferris obtained copies of Gardena Police Department report, Los Angeles Fire Department report, Harbor UCLA Medical Records, Kaiser Permanente Medical Records which included medical records review, interviews with Administrator #1-2 (A1-A2), Staff #1-5 (S1-S5), Clients #1-5 (C1-C5), Witness #1-3 (W1-W3).

The investigation revealed the following:

Allegation: Resident tested positive for Fentanyl due to staff neglect.
It is alleged that on 04/03/23, Client #1 was admitted to Harbor-UCLA Medical Center where a urinalysis test was conducted and the result was positive for fentanyl and benzodiazepine. On 04/04/23, the client was transferred to Kaiser Permanente Hospital where another urinalysis was conducted and the test was positive for benzodiazepines, but negative for fentanyl. As a part of the investigation LPA conducted a file review which revealed Resident #1 was admitted to 164th Place on 2/4/23. IB investigator interviewed A1-A2 and 2 or 2 Administrators denied giving C1 Fentanyl & Benzodiazepine. A1 stated C1 does not go out into the community independently and is always supervised by staff. A1 stated C1 usually only has one visitor from Westside Regional Center Supportive Living visit C1. A1 stated R1 was given Haloperidol at the hospital which has been known to cause false positive drug test results. IB investigator interviewed Staff #1-5 and 5 of 5 staff denied giving C1 Fentanyl and Benzodiazepine. IB investigator interviewed Clients #1-5 and 2 or 5 clients denied having any issues at the facility; 3 of 5 clients were unable to answer IB investigator Ferris questions due to their disability.

Per the client’s medication administration record, Harbor-UCLA Medical Center medical records, Kaiser Permanente Hospital – WLA medical records, and L.A. County Fire Department records documented that Client #1 was not prescribed fentanyl or benzodiazepines. Client #1 was not administered fentanyl or benzodiazepines at either hospitals or during the ambulance transportation. Client #1’s Primary Care Physician stated that the client’s prescribed medications would not result in a positive urinalysis test for fentanyl or benzodiazepines. Witness #2 from Westside Regional Center was interviewed and stated, C1 does not leave the facility unsupervised, and did not have a history of purchasing medication(s) without a prescription.

(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230404140605
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: 02/10/2024
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
IB investigator conducted a review of Clients #2-5 medications and per clients (within the facility) at the time were not prescribed fentanyl, but one (1) client was prescribed Lorazepam (a benzodiazepine) to be given as needed. Medications are stored in a locked cabinet only accessed by the medication technicians.

Based on records reviewed, interviews conducted there is insufficient evidence to determine if Client #1 was provided fentanyl by facility staff. Although the allegation may have happened or Is valid there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated.

An exit interview conducted with Direct Support Provider (S6: Jerome Alejo Busuego) and House Manager (S5: Hai Nguyen) and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3