198320460-9-4-2025-11-AS-EMAZ-DLMV7P-20250918161128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320460
Report Date: 09/04/2025
Date Signed: 09/04/2025 11:37:31 AM

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
08/14/2025 and conducted by Evaluator Deborah Lee

COMPLAINT CONTROL NUMBER: 11-AS-20250814193323

FACILITY NAME:	MOUNTAIN TOP - E. SILVA		FACILITY NUMBER:	198320460
ADMINISTRATOR:	COREY SPIGHT		FACILITY TYPE:	737
ADDRESS:	1910 E. SILVA STREET		TELEPHONE:	(760) 218-4293
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY:	4	CENSUS: 4	DATE:	09/04/2025
		UNANNOUNCED	TIME BEGAN:	08:12 AM
MET WITH:	Dolores Cespedes		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are retaining a resident who requires a higher level of care
Staff are not trained to meet the needs of residents in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On September 4, 2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced visit to this facility to continue investigation of the above allegations and to deliver findings. LPA was met by Administrator Dolores Cespedes and explained the purpose of the visit.

Investigation consisted of the following:

On 8/21/25 LPA Lee interviewed Administrator (A1), obtained and reviewed the following documents: Staff roster (dated 7/13/25), Client roster (dated 6/6/25), Staff roster (dated 7/13/25),Client roster (dated 6/6/25),S1-S6 Registered Behavior Tech (RBT) certificates Staff ratio documentation (August 2025) , C4’s Individual Behavior Support Plan (IBSP) for May/June, staff training (CPI, DSP 1 & 2), interviewed 6 staff (S1-S6), Behavior Specialist (W1).

Page 1 of 3

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

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-20250814193323

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: 09/04/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Investigation revealed the following:

Allegation: Staff are retaining a resident who requires a higher level of care

The detail of the complaint alleges that “C1 hits himself a lot on his head and body to the point of leaving marks and is red and bangs on doors all day. We cannot help him here.”

On 8/21/25, LPA interviewed A1 who denied allegation stating C1 is supported by 2:1 staffing ratio, and when he is out in the community a 3:1 ratio. A1 went on to state that staff are also supported by placement agency’s Behavior Specialists in addition to a facility Behavior Specialist who come to give staff techniques on how to deal with client behaviors.

On 8/21/25, LPA interviewed 6 staff (S1-S6) regarding the above allegation and of those interviewed, 5 out of 6 denied the allegation, stating that they can handle C1’s behaviors. 1 out of 6 stated that some staff can’t handle C1’s behaviors because they haven’t had experience with “extreme behaviors that C1 exhibits.”

On 8/21/25, LPA obtained, reviewed, and evaluated a copy of C1’s Individual Behavior Support plan for May and June 2025 which indicates that the Behavior Specialists are working with C1 on a consistent basis.

On 8/21/25, LPA spoke with Behavior Specialist (W1) from the Department of Developmental Services (DDS) via telephone who stated that C1 is in the highest level of care in a community care setting and that C1 has behavior challenges, but it is C1’s first placement and C1 is adjusting. W1 expressed that she can reach out to the Placement Agency to discuss the need for additional support to assist the staff.

Page 2 of 3

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250814193323

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: 09/04/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews conducted, observations made, and documents reviewed, there is insufficient evidence to support the 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 UNSUBSTANTIATED

Allegation: Staff are not trained to meet the needs of residents in care.

The detail of the complaint alleges that the staff “do not have the proper training help C1”

On 8/21/25, LPA Lee interviewed A1 who denied allegation stating that all the staff at the facility have proper and relevant experience to work at the facility. She went on to state that all the staff have the following certifications: Registered Behavior Tech (RBT), Direct Support Professional (DSP), and Crisis Prevention Institute (CPI). Lastly, A1 stated that staff participate in ongoing in-service training provided by the facility.

On 8/21/25, LPA interviewed 6 staff (S1-S6) regarding the above allegation and of those interviewed, 6 out of 6 denied the allegation, stating that they have relevant experience working with clients with behavior challenges.

On 8/21/25, LPA obtained, reviewed, and evaluated the following: RBT certifications (dated 6/27/25, 9/27/19, 4/29/24, 7/16/25, 2/14/24), CPI certifications (dated: 5/7/25, 6/5/25, 12/6/24, 5/20/25, 6/25/25), and DSP certifications (5/25/25, 5/27/25, 5/5/25, 5/29/25)

Based on interviews conducted and documents reviewed, there is insufficient evidence to support the 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 UNSUBSTANTIATED

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

Page 3 of 3

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Deborah Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3