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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 02/14/2024
Date Signed: 02/26/2024 11:04:57 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:
02/14/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mariel VenturaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff leave resident confined to their wheelchair for an extended period of time while in care.
Resident sustained unexplained injury due to staff neglect.
Staff are not seeking medical attention for resident as needed.
INVESTIGATION FINDINGS:
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On 02/14/24 at 9:00 a.m., Licensing Program Analyst (LPA) Lizeth Villegas conducted a subsequent 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 02/14/24 LPA conducted a review of skill acquisition date sheet and progress data sheets for R1 dated December 2023, January 2024, and February 2024, obtained copy of April 2023 Physical therapy consultant training log, April 2023 Inservice training for Autisim spectrum and intellectual disabilities overview, a copy of R1's Podiatrist visit summary, and patient visit summaries for R2 dated 01/08/24 and 02/05/24. On 02/14/24 LPA conducted a file review, IPP review, and conducted interview with W3.
The investigation revealed the following:
Allegation: Staff leave resident confined to their wheelchair for an extended period of time while in care. It is being alleged R1 and R2 are left in their wheelchairs for an extended period of time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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: 02/14/2024
NARRATIVE
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On 12/28/24 LPA interviewed Administrator (A1) regarding the allegation above, A1 denied the allegation stating that residents are R1 and R2 are removed from wheelchairs at 2pm upon arrival from day program, R1 and R2 are placed back into the wheelchairs between 5-6pm for dinner time, and placed in bed between 7-8pm. On 12/28/23 LPA interviewed staff #1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above stating R1 and R2 are removed from their wheelchairs as needed for comfort and to avoid any soars or injuries. On 12/28/23 LPA interviewed R1 regarding the allegation above, R1 denied the allegation above and reported sitting on the couch and recliner when not in the wheelchair. On 12/28/23 LPA was unable to interview R2-R4 as R2-R4 unable to answer LPAs questions. On 02/06/24 LPA interviewed W2 regarding the care being provided for R1-R3, W2 reported there are no concerns regarding the care the facility staff is providing. On 02/14/24 LPA interviewed W3 regarding the care being provided to R4, Per W3 there are currently no health and safety concerns regarding the care the facility has been providing to R4 during placement. On 12/28/23 and 02/08/24 LPA observed R1 being transferred from couch to chair.

Allegation: Resident sustained unexplained injury due to staff neglect.
It is being alleged resident sustained unexplained injury due to staff neglect. On 12/28/24 LPA interviewed Administrator (A1) regarding the allegation above, A1 denied the allegation reporting rounds are conducted every 20-30 minutes to ensure all residents are doing fine. On 12/28/23 LPA interviewed staff #1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above and stated there have not been any injuries, 1 of 3 staff interviewed stated that if any any small bruise or scratch were observed it is reported and a picture is taken. On 12/28/23 LPA interviewed R1 regarding the allegation above, R1 denied the allegation above and reports R1 likes living at the facility. On 12/28/23 LPA was unable to interview R2-R4 as R2-R4 unable to answer LPAs questions. On 02/06/24 LPA interviewed W2 regarding the care being provided for R1-R3, W2 reported there are no concerns regarding the care the facility staff is providing. On 02/14/24 LPA interviewed W3 regarding the care being provided to R4, Per W3 there are currently no health and safety concerns regarding the care the facility has been providing to R4 during placement. On 12/28/23 and 02/08/24 LPA did not observed any bruising or abrasions on R1-R4 nor observed any incident reports regarding bruising. On 02/14/24 LPA reviewed IPP for R1-R4, per IPP's, R1 does not engage in disruptive social behaviors, aggressive social behaviors nor self-injurious behaviors,R2 has exhibited unsettled behaviors, R3 requires constant supervision for safety and well-being and to prevent injury and harm to self.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 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: 02/14/2024
NARRATIVE
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Allegation: Staff are not seeking medical attention for resident as needed.
It is being alleged staff are not seeking medical attention for resident as needed. On 12/28/24 LPA interviewed Administrator (A1) regarding the allegation above, A1 denied the allegation reporting residents are taken to their medical appointments and follow ups as needed. On 12/28/23 LPA interviewed staff #1-3 (S1-S3) regarding the allegation above, 3 of 3 staff interviewed denied the allegation above stating that staff will report and consult with administrator, provide transportation to urgent care or call 911 when it is an emergency. On 12/28/23 LPA interviewed R1 regarding the allegation above, R1 denied the allegation above and reported receiving medical attention some times as it cannot be all the time. On 12/28/23 LPA was unable to interview R2-R4 as R2-R4 unable to answer LPAs questions. On 02/06/24 LPA interviewed W2 regarding the care being provided for R1-R3, W2 reported there are no concerns regarding the care the facility staff is providing and states facility is good with getting residents to appointments and communicating upcoming appointments. On 02/14/24 LPA interviewed W3 regarding the care being provided to R4, Per W3 there are currently no health and safety concerns regarding the care the facility has been providing to R4. On 02/14/24 LPA reviewed visit summaries for R1-R2 and confirmed residents are obtaining medical attention when needed.

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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3