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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 06/06/2024
Date Signed: 06/06/2024 03:44:04 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
05/28/2024 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20240528231326
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:
06/06/2024
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Mariel Ventura/AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure a client's postural support was properly used while in care.
Staff did not follow a licensed physician's orders.
INVESTIGATION FINDINGS:
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On 6/6/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Mariel Ventura/Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Client’s interviews (C#1-C#4), Staff Interviews (S#1-S#3) and Witness interviews (W#1 and W#2). LPA obtained and reviewed the following documents: Client’s roster, Personnel roster, (C#1-C#4) Identification and Emergency Information, (C#1-C#4) Admissions agreements, (C#1-C#4) Physicians Report for Residential Care Facilities for the Elderly, (C#1-C#4) Needs and Services Plan, (C#1-C#4) Medication Administration Record (MAR) for the month of May 2024, copies of staff training regarding postural supports, copy of (C#1)’s medical prescription of gait belt by physician.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
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 4
Control Number 11-AS-20240528231326
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: 06/06/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Staff did not ensure a client's postural support was properly used while in care.

The details of the complaint alleged that facility staff is not ensuring client’s postural support was properly used while in care.



During the records review, LPA Iniguez reviewed the following: (C#1)'s Home Health Plan of Care signed by MD on 10/24/23. In the plan of care for (C#1), it is prescribed by MD Durable Medical Equipment - Gait Belt with a start date of 10/24/2023 and no End Date. The goal is for (C#1) to ambulate 50 feet using FWW (belt), with the level of assistance: mod assist to allow ambulation within the B&C facility, to be achieved by date: 11/21/23.

On 6/6/24, when arriving at the facility, LPA Iniguez noticed (C#1) wearing their gait belt while seated in their wheelchair.



During an interview with the administrator (A#1), she stated that only one client uses postural support and is currently living in the community. Also, (A#1) stated that they do have on file a doctor’s order for (C#1)’s gait belt, and the facility staff just took training on April 24, 2024.

During an interview with client 1 (C#1), they stated that they use postural supports, and the facility staff assists them in using them. Also, (C#1) stated that they always wear gait belts. In addition, (C#1) stated that they like living at the facility.

During interviews with clients (C#2-C#4), (2) out of (3) stated that they do not use postural supports, but the facility staff helps them with their needs, and they like living at the facility. (1) out of (3) clients refused to be interviewed by LPA during the visit.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20240528231326
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: 06/06/2024
NARRATIVE
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During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that there’s only one client that uses postural support currently living at the community, and the facility does have on file a doctor’s orders for (C#1)’s gait belt. Also, (3) out of (3) facility staff stated that they just took training on April 24, 2024, regarding postural supports.

During interviews with Witnesses (W#1 and W#2), both stated that they had indeed observed (C#1) wearing their gait belt during their visits to the facility.

Allegation: Staff did not follow a licensed physician's orders.

The details of the complaint alleged that facility staff are not following licensed physician’s orders.



During the records review, LPA Iniguez reviewed the following: (C#1)’s MD order for Durable Medical Equipment dated 10/24/22. The medical order does not state if a gait belt must be used under or over (C#1)’s clothes. The MD wrote no special comments and no end date. In addition, LPA reviewed the facility staff training records regarding how to transfer a person using a gait belt. This training was taken on 4/24/24.

During an Interview with the Administrator (A#1), she stated that the facility always follows the doctors’ orders regarding (C#1)’s postural support-gait belt. Also, (A#1) stated that (C#1) has never used postural support contrary to what the doctor prescribed for (C#1).

During an interview with client 1 (C#1), they stated that their gait belt is always on, and they wear it.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20240528231326
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: 06/06/2024
NARRATIVE
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During an interview with client 1 (C#1), they stated that their gait belt is always on, and they wear it.

During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that they always follow the doctors’ orders regarding (C#1)’s postural support-gait belt and have not used the gait belt contrary to the MD prescription.

During interviews with witnesses (W#1 and W#2), both stated that the facility has the doctor’s prescription for postural support in (C#1)’s file.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.


An exit interview was conducted, and a copy of the Complaint Report was given to Mariel Ventura /Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4