198320460-9-9-2024-11-AS-WGIS-D8XVCC-20240909161854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320460
Report Date: 09/09/2024
Date Signed: 09/09/2024 04:19:04 PM

Document Has Been Signed on 09/09/2024 04:19 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	MOUNTAIN TOP - E. SILVA		FACILITY NUMBER:	198320460
ADMINISTRATOR/ DIRECTOR:	BRADSHAW, AMANDA		FACILITY TYPE:	737
ADDRESS:	1910 E. SILVA STREET		TELEPHONE:	(760) 218-4293
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90807
CAPACITY: 4		CENSUS: 0	DATE:	09/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Amanda Bradshaw		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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	On 09/09/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an announced Pre-Licensing visit to the facility listed above. During today’s visit, LPA met with Licensee, Bertha Martin and Administrator, Amanda Bradshaw and the purpose of the visit was explained. The facility has been approved to serve four (4) developmentally disabled clients ages 18-59. Bedrooms two (2) through four (4) have been approved for ambulatory clients and bedroom one (1) is approved for a non-ambulatory client. Physical Plant/Structure The facility is a single-story structure in a residential neighborhood. The facility consists of four (4) bedrooms, two (2) full bathrooms, one (1) half bathroom, living room, sitting room, dining room, kitchen, laundry room, detached garage, and outside shaded patio area. LPA observed the front yard and backyard are well maintained. LPA observed a shaded patio area with table and chairs available. LPA observed all walkways were clean, clear, and free of debris, hazards, and obstructions. Gates exiting the property open easily from the inside to exit onto the street. Handrails along outside ramps and stairs are secured. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all client bedrooms and observed the walls and floors to be clean and in good repair. LPA observed all bedrooms have the required furniture

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MOUNTAIN TOP - E. SILVA	FACILITY NUMBER: 198320460
	VISIT DATE: 09/09/2024

NARRATIVE

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including a bed, dresser, nightstand, chair, and storage space for personal belongings. LPA observed all rooms have ample lighting and a nightlight attached to the headboard. LPA observed all beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows, in good repair. LPA observed, in each client bedroom there is an additional comforter in the closets. An additional supply of lines was observed in a cabinet in the bathroom. All bedrooms were observed with ample lighting.

Bathrooms LPA inspected all bathrooms and found them to be within Tittle 22 regulations. All bathrooms were observed clean and operational. LPA observed baskets with personal hygiene products for each individual client. LPA observed an ample supply of towels available for clients in a cabinet in the bathroom. All showers have a nonskid mat, and the non-ambulatory bathroom has secured safety handrails. The water temperature in the bathrooms measured 117.6-degrees, 117.9-degrees and 118.0-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 117.9-degrees Fahrenheit. All sharps are secured in a locked box in a locked cabinet under the kitchen sink and are inaccessible to clients. All cleaning supplies are secured in a locked cabinet under

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MOUNTAIN TOP - E. SILVA	FACILITY NUMBER: 198320460
	VISIT DATE: 09/09/2024

NARRATIVE

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the kitchen sink and in a locked cabinet in the laundry room and are inaccessible to clients.
Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with a sofa, love seat sofa, and a chaise chair to accommodate all clients. In the sitting room, LPA observed four (4) recliners for client use. LPA observed an ample supply of games, activities, reading material and puzzles available. The dining room table is large enough to accommodate clients for meals. LPA observed all walkways and hallways to be clean, clear, and free of hazards and obstructions. All rooms were observed with ample lighting. The facility has internet service available for clients. The facility was kept at a comfortable temperature.

Safety LPA observed three (3) fully charged fire extinguisher, one mounted on the wall near the living room, one mounted on the wall in the sitting room and one mounted on the wall in the garage. All smoke and carbon monoxide detectors are operable. LPA inspected the First Aid Kit and observed it had the required items. The facility sketch was observed posted throughout the facility. All exits are marked with an EXIT sign. The facility’s Emergency and Disaster Plan was observed posted on a board in the dining room. LPA observed the facility’s emergency supplies in a trash can and a plastic tote in the garage. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

Page: 3 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: MOUNTAIN TOP - E. SILVA	FACILITY NUMBER: 198320460
	VISIT DATE: 09/09/2024

NARRATIVE

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Medications LPA observed that Centrally Stored Medications will be secured in a locked cabinet, in the laundry room, and are inaccessible to clients. LPA observed the notebook the Medication Administration Record (MAR) will be kept.

Infection Control LPA observed an ample supply of cleaning supplies. LPA

observed an ample supply of paper towels. All trash cans have a lid.

Files Client and staff files will be secured in a locked cabinet in the laundry room.

Component III- LPA reviewed Component III with the licensee and administrator.

During today’s visit, LPA did not observe any advisory recommendations.

An exit interview was conducted with Administrator, Amanda Bradshaw, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC809 (FAS) - (06/04)

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