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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320080
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:54:36 PM

Document Has Been Signed on 09/17/2021 01:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
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:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Linda WhitfordTIME COMPLETED:
01:55 PM
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On 9/17/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with Administrator Linda Whitford and Hai Nguyen and explained the purpose of today’s visit is to complete the infection control annual. The facility is licensed for 4 clients, 2 ambulatory, 2 non-ambulatory. Facility has a fire clearance for 2 ambulatory and 2 non-ambulatory.

The facility is a one-story home located in a residential neighborhood. The facility consists of the following: four (4) resident bedrooms, two (2) bathrooms, dining area, kitchen, living room, office area and shaded patio area in the backyard.

LPA and staff toured the physical plant. There were no obstructions on the premises or small bodies of water. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Five (5) smoke detectors were observed to be hardwired and interconnected. Facility has one fire extinguishers, fully charged.

Due to time constraints, visit will have to be continued at another time.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Hai Nguyen, Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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