198320080-4-9-2025-11-AS-RORN-DGQ359-20250515175623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320080
Report Date: 04/09/2025
Date Signed: 04/09/2025 03:45:05 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
03/12/2025 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20250312092426

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:	04/09/2025
		UNANNOUNCED	TIME BEGAN:	03:19 PM
MET WITH:	Joy Suarez, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Unqualified staff are administering medications to residents.
Unqualified staff are providing care and supervision to residents.

INVESTIGATION FINDINGS:

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On 4/9/25, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced subsequent visit to this facility. LPA was met by the Administrator, Joy Suarez and explained the purpose of the visit is to complete investigation and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following: On 3/13/25 LPA reviewed staff files and interviewed Staff 1 through Staff 4. Licensing Program Analyst (LPA) Felisa Shirley reviewed staff files and requested copies of the following records: LIC 500, Direct Support Provider (DSP) trainings and Medication Administration Training for staff. On 4/9/25, LPA interviewed Client 1. Client 2 is not available, and Client 3 and Client 4 are nonverbal.

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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-20250312092426

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: 04/09/2025

NARRATIVE

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The investigation revealed the following:

Allegation: Unqualified staff are administering medications to residents

On 4/4/25, LPA Shirley reviewed, In-Service Staff Training completed on 11/23/24 and observed that S1 through S4 were trained for, Medication Administration. The topics included, Medications and Side effects, Prescriptions, Assisting with Medication Administration, and Documenting Medication Administration in the Medication Administration Record, (MAR).

LPA Shirley spoke with and interviewed staff 1 thru staff 4 (S1 thru S4). LPA asked if unqualified staff dispensed medications to clients. Of those interviewed, 4 out of 4 staff denied the allegation. LPA Shirley interviewed client 1 (C1). LPA asked, if he felt that staff are qualified to dispense medications to him. C1 stated yes, C2 was not available and C3 and C4 are nonverbal.

Regarding the allegation, “Unqualified staff are administering medication to residents,” the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Unqualified staff are providing care and supervision to residents.

On 3/31/25 LPA Shirley reviewed staff records and observed copies of DSP trainings for S1 through S4.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250312092426

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: 04/09/2025

NARRATIVE

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LPA Shirley interviewed staff 1 thru staff 4 (S1 thru S4). LPA ask, is unqualified staff providing care and supervision to residents. Of those interviewed, 4 out of 4 denied the allegation. LPA Shirley interviewed client 1 (C1). LPA asked, if he felt that unqualified staff are providing care and supervision to residents. C1 stated no, C2 was not available and C3 and C4 are nonverbal.

Regarding the allegation, “Unqualified staff are providing care and supervision to residents,” the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Joy Suarez.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC9099 (FAS) - (06/04)

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