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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320460
Report Date: 08/21/2025
Date Signed: 08/27/2025 08:36:07 AM

Substantiated


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
08/12/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250812101037
FACILITY NAME:MOUNTAIN TOP - E. SILVAFACILITY NUMBER:
198320460
ADMINISTRATOR:COREY SPIGHTFACILITY TYPE:
737
ADDRESS:1910 E. SILVA STREETTELEPHONE:
(760) 218-4293
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:4CENSUS: DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Dolores CespedesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff do not ensure residents have access to hazardous chemicals.
INVESTIGATION FINDINGS:
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On August 21 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced visit to this facility to continue investigation of the above allegation and to deliver findings. LPA was met by Administrator Dolores Cespedes and explained the purpose of the visit. LPA was granted access to the facility.

The investigation consisted of the following:

On 8/14/25, LPA interviewed Administrator (A1). LPA obtained and reviewed the following documents:
Staff roster (dated 7/13/25),Client roster (dated 6/6/25), shift duties document (dated 8/14/25), Assigned client ratio shift documentation (dated August 2025 ). S7 disciplinary documentation. On 8/21/25, LPA interviewed 6 staff (S1-S6).

page 1 of 2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
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 5
Control Number 11-AS-20250812101037
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: MOUNTAIN TOP - E. SILVA
FACILITY NUMBER: 198320460
VISIT DATE: 08/21/2025
NARRATIVE
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Investigation revealed the following:

Allegation: Staff do not ensure residents have access to hazardous chemicals.

The detail of the complaint alleges that "chemicals are left in clients rooms unattended.

On 8/14/2025 at 11:30am, LPA interviewed Administrator Dolores Cespedes (A1) who did not deny the allegation. A1 informed LPA that there was an incident on 7/11/25 where a bottle of “bleach water” was left in a client’s room while the staff (S7) was assisting client clean his bed, but during the transition (between shifts), the bleach water was left on the floor in client’s room, another staff found the bottle of bleach secured it and and reported it her superior. Disciplinary action was taken against the S7 who did not properly secure the cleaning solution after use. A1 further stated that “we are planning an in-service training on properly securing toxins in the facility.
On 8/21/25, LPA Lee interviewed 6 staff members regarding the allegation and of those interviewed, (6 ) out of (6) denied allegations stating that they have never left toxins out nor have they witnessed any other staff leaving toxins out.

On 8/14/25, LPA obtained and reviewed, S7's disciplinary documentation which indicated S7 violated safety rules and issued a written warning and counseling.

Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANIATED. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D. A copy of report provided along with appeal rights.

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SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250812101037
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: MOUNTAIN TOP - E. SILVA
FACILITY NUMBER: 198320460
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2025
Section Cited
CCR
80087(g)
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Buildings and Grounds: 80087(g)
Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
This requirement was not met by evidence of:
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Administrator will conduct a training for all staff regarding the importance of toxins remaining inaccessible to clients at all times. Administrator to submit via email sign in sheet and training materials by POC due date 8/22/25.
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Based on interviews, it was revealed that on 7/11/25 a bottle of “bleach water” was left in a client’s room while the staff (S7) was assisting client clean his bed; which poses an immediate health, safety risk to clients in care.
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The facilty took disciplinary action against the S7 who did not properly secure the cleaning solution after use. Copy of written disciplinary action was provided to LPA at time of visit.
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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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
08/12/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250812101037

FACILITY NAME:MOUNTAIN TOP - E. SILVAFACILITY NUMBER:
198320460
ADMINISTRATOR:COREY SPIGHTFACILITY TYPE:
737
ADDRESS:1910 E. SILVA STREETTELEPHONE:
(760) 218-4293
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:4CENSUS: DATE:
08/21/2025
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Dolores Cespedes TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff do not ensure residents do not have access to sharp objects.
INVESTIGATION FINDINGS:
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On August 21, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced subsequent visit to this facility to continue the investigation of allegation above and to deliver findings. LPA was met by Administrator Dolores Cespedes and explained the purpose of the visit. LPA was granted access to the facility.
Investigation consisted of the following:
On 8/14/25, LPA interviewed Administrator (A1). LPA obtained and reviewed the following documents: Staff roster (dated 7/13/25),Client roster (dated 6/6/25), Lastly LPA toured facility. On 8/21/25, interview 6 staff (S1-S6) and 2 clients (C1-C2)

Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250812101037
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: MOUNTAIN TOP - E. SILVA
FACILITY NUMBER: 198320460
VISIT DATE: 08/21/2025
NARRATIVE
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Investigation revealed the following:

Allegation: Staff do not ensure residents do not have access to sharp objects.

The detail of the complaint alleges

On 8/14/2025 at 11:30am, LPA interviewed Administrator Dolores Cespedes (A1) who denied allegations stating that knives are always secured and locked. On 8/21/25 LPA interviewed 6 staff regarding the allegation and of those interviewed, 6 out of 6 denied allegation stating that they have never left knives out nor have they witnessed any other staff leaving knives out for clients to have access. On 8/21/25, LPA interviewed 2 clients (C1-C2) who stated that they have never had access to knives while in the facility.

Based on interviews conducted there is insufficient evidence to support above allegation 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 UNSUBSTANCIATED

There were no deficiencies cited during today's visit. Exit interview conducted and copy of report was provided.

Page 2 of 2

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5