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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320460
Report Date: 09/04/2025
Date Signed: 09/04/2025 12:20:19 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
08/07/2025 and conducted by Evaluator Deborah Lee
COMPLAINT CONTROL NUMBER: 11-AS-20250807095547
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: 4DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Dolores Cespedes TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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License does not ensure lead staff have adequate experience providing direct care to clients with developmental disabilities.
Staff do not ensure adequate care supervision is provided to clients.
Staff do not ensure the facility is kept in clean sanitary conditions for clients in care.
Staff do not ensure expired food is discarded from the facility.
Licensee does not ensure facility has sufficient supply of food in the home for clients in care.
Licensee does not ensure sufficient hygiene supplies are provided to clients in care
INVESTIGATION FINDINGS:
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On September 4, 2025 Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced visit to this facility to continue investigation and to deliver findings. LPA was met by Administrator Dolores Cespedes and explained the purpose of the visit.

Investigation consisted of the following:
On 8/14/25 LPA Lee interviewed Administrator (A1), 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 ), S1-S6 Registered Behavior Tech (RBT) certificates Staff ratio documentation (August 2025) , C1-C4 Individual Behavior Support Plan (IBSP) for May/June, staff training (CPI, DSP 1 & 2) and grocery receipts (July 2025). Lastly, LPA observed the facility food supply and facility's hygiene supply
On 8/21/25 LPA conducted interviews with 6 staff (S1-S6) staff interviews and 2 clients (C1-C2).

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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 7
Control Number 11-AS-20250807095547
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
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Investigation revealed the following:

Allegation: License does not ensure lead staff have adequate experience providing direct care to clients with developmental disabilities

The detail of the allegation alleges that “people [staff] do not have relevant experience to work here.”

On 8/14/25, LPA Lee interviewed A1 who denied allegation stating that all the staff at the facility have the 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 had at least a year of prior relevant experience working with clients with behavior challenges.

On 8/14/25, 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.

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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 7
Control Number 11-AS-20250807095547
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
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Allegation: Staff do not ensure adequate care supervision is provided to clients

The detail of the complaint alleges that there is a lack of staff due to “call outs.” Additionally, it is alleged that the schedule says there is adequate staffing, but there is not adequate staffing.

On 8/14/25, LPA interviewed A1 who denied the allegation stating that the facility have adequate staffing. A1 further stated that “when call outs happen, we select from a pool of on call staff, also I will step in if need be to assist.”

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 there is sufficient staff to meet the clients’ needs.

On 8/14/25, LPA obtained, reviewed, and evaluated the staff to client ratio schedule. LPA observed that the ratios were consistent with what was on the schedule.

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.

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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 7
Control Number 11-AS-20250807095547
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
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Allegation: Staff do not ensure the facility is kept in clean sanitary conditions for clients in care

The detail of the complaint alleges that facility is “dirty and gross.”

On 8/14/25, LPA interviewed A1 who denied allegation stating, “on each shift there are duties that staff are responsible for and among those duties is cleaning.”

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 all staff are responsible for maintaining a clean and sanitary facility.

On 8/14/25 and 8/21/25 LPA observed that the facility was clean, sanitary and free of odors.

On 8/14/25, LPA obtained a copy of the facility’s shift duties document where each assigned duty was initialed by the assigned staff upon completion of task.

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.

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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: 4 of 7
Control Number 11-AS-20250807095547
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
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Allegation: Staff do not ensure expired food is discarded from the facility.

The detail of the complaint alleges that “the freezer has old food.”

On 8/14/25, LPA interviewed A1 who denied allegation stating the facility does not keep expired food and that it is immediately discarded if found. A1 further stated “ensuring that all food in fridge is dated and old food is discarded is one of the duties on our shift duties list for staff to complete.”

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 there is no expired food in the facility and that one of their duties is to make sure that food is properly dated, and any expired food found is thrown away.

On 8/14/25, LPA inspected the food supply in the facility and found the food was properly labeled and no expired food was observed.

Based on interviews conducted and observations made, 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: Licensee does not ensure the facility has sufficient supply of food in the home for clients in care

The detail of the complaint alleges that facility “run out of food all the time.”

On 8/14/25, LPA Lee interviewed A1 who denied allegation stating the facility has never run out of food, that shopping is done on a weekly basis.

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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: 5 of 7
Control Number 11-AS-20250807095547
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
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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 the facility has never run out of food, and there is usually an abundance of food in the facility.

On 8/21/25, LPA interviewed 2 clients (C1-C2) regarding the above allegation and of those interviewed 2 out of 2 stated that they get enough to eat and the facility has never run out of food.

On 8/14/25 LPA inspected the food supply and observed that there was plenty of food on hand.

On 8/14/24, LPA obtained copies of grocery receipts (dated 6/27/25, 7/10/25, 7/14/24, 7/17/25, 7/24/25, 7/31/25, and 8/8/25) indicating that shopping is done on a weekly basis as reported.

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: Licensee does not ensure sufficient hygiene supplies are provided to clients in care

The detail of the allegation alleges the facility always runs out of toilet paper, paper towels and soap.

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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: 6 of 7
Control Number 11-AS-20250807095547
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
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On 8/14/25, LPA interviewed A1 who denied allegation stating the facility has never run out of hygiene supplies. A1 further stated that “we purchase those items weekly.”

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 the facility has never run out of hygiene supplies and when they get low, they go to the store to replenish the supply.

On 8/21/25, LPA interviewed 2 clients (C1-C2) regarding the above allegation and of those interviewed, 2 out of 2 stated that the facility has never run out of hygiene supplies they get what they need when they need it.

On 8/14/25, LPA observed that there was an ample supply of hygiene products on hand in the facility.

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

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

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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: 7 of 7