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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201950
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:54:47 AM


Document Has Been Signed on 08/10/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:VIEW AT LADERA HEIGHTS, THEFACILITY NUMBER:
198201950
ADMINISTRATOR:SAMUELS, VALRIE A.FACILITY TYPE:
740
ADDRESS:5540 BEDFORD AVETELEPHONE:
(310) 337-9120
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY:6CENSUS: 1DATE:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Angellee Palmer/StaffTIME COMPLETED:
11:50 AM
NARRATIVE
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On 8/10/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Angellee Palmer /Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above of which (6) may be non-ambulatory. Facility has an approved hospice waiver for (1) patient.

The facility is a two-story home in a residential neighborhood. On the first floor there are four (4) bedrooms, three (3) bathrooms, kitchen, office space, sitting room, dining room, living room and garage. The second floor has two (2) bedrooms and two (2) bathrooms occupied by the licensee.



The front and back yard are well landscaped with perimeter fences and self-latching/slider gates. The front entrance has a ramp. The back yard has a pool and jacuzzi that have a perimeter gate that locks and secures pool from resident entry. There is a shaded area with ample seating and tables in the backyard. All walkways are clear of any obstructions, hazards, or debris.

LPA Iniguez toured the physical plant with staff. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 106.7°F, Bathroom #1:105.7°F.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: VIEW AT LADERA HEIGHTS, THE
FACILITY NUMBER: 198201950
VISIT DATE: 08/10/2023
NARRATIVE
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (1) residents' service files, (1) staff personnel files and (1) Medication Administration Records (MAR) were maintained in order. First AID kit was checked.

LPA observed the facility's infection control practices.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Amyline Simpson/Owner.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/10/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VIEW AT LADERA HEIGHTS, THE
FACILITY NUMBER: 198201950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in keeping cleaning solution and desinfectants locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee will remove immediately the cleaning solutions, disinfectants and knifes and locked them away. In addition, licensee will ensure all staff is re-trained on how to keep cleaning solutions and disinfectants locked all the time, a copy of this training will be sent to LPA before POC due date via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/10/2023 11:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: VIEW AT LADERA HEIGHTS, THE
FACILITY NUMBER: 198201950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in staff having a expired CPR card on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee will ensure all staff CPR are not expired and will submitt proof of renew CPR to LPA before POC due date via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4