198320460-4-15-2026-11-AS-UCOL-DTET5K-20260423142540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320460
Report Date: 04/15/2026
Date Signed: 04/15/2026 05:05:47 PM

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
04/08/2026 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260408093853

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: 3	DATE:	04/15/2026
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Joline Duenas		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not dispense medications as prescribed.
Staff did not follow required medication destruction procedures.

INVESTIGATION FINDINGS:

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On 04/15/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with Joline Duenas.

Investigation consisted of the following: On 04/15/2026, LPA obtained Personnel Record, Register of Clients, and Client #1 - #4 Records. LPA reviewed three client medications and reviewed four client Medication Administration Records and Centrally Stored Medication and Destruction Logs. LPA interviewed Staff #1 – 3 and Witnesses #1 – 3. LPA left voicemails for two Responsible Parties and attempted to interview two clients. One client was away from the facility during the client interviews.

Investigation revealed the following:
Continue to LIC9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

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 4

Control Number 11-AS-20260408093853

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: 04/15/2026

NARRATIVE

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Allegation: Staff did not dispense medications as prescribed
Record review of Medication Administration Record (April 2026) revealed Client #3 (C3) received Pantoprazole Sod Dr 40 MG from 04/01/26 – 04/15/26 AM. LPA observed Pantoprazole Sod Dr 40 MG in the bubble packet for 04/07/26. LPA revealed the discrepancy to Staff #1 and Staff #4. One out of three witnesse (W1 – W3) interviews indicated complaints have been made about medication not being dispensed as prescribed.

Regarding the allegation, “Staff did not dispense medications as prescribed,” based on record review and observation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC 9099D.

Allegation: Staff did not follow required medication destruction procedures
Record review of the facility’s medication policy revealed medication which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. Both shall sign a record, to be retained for at least one year, which lists the following: name of the client, the prescription number and the name of pharmacy, the drug name, strength and quantity destroyed, and the date of destruction… Record review of Client #1’s (C1) Centrally Stored Medication and Destruction Record (CSMDR) (December 2025) revealed Gamma Aminobuturic Acid and Buspirone was disposed on 12/01/25 and it does not include a witness signature. Aripiprazole and Benztropine was disposed of on 12/06/25 and it does not include a witness' signature. Review of Client #2’s (C2) CSMDR (February 2026) revealed melatonin was disposed of on 02/11/26 and it does not include a signature. CSMDR (December 2025) revealed Gummies were destroyed on 01/02/26 and 01/08/26 and it is missing signatures from a representative and witness. Review of Client #4’s (C4) CSMDR (January 2026) revealed Lamatrigine 100mg was disposed on 01/17/26. It does not include a witness’ signature. Review of CSMDR (December 2025) revealed Hydroxyzine HCL was disposed on 12/05/25 and it does not include a witness' signature. Lamotrigine 25 MG was disposed on 12/19/25 and it does not include a witness' signature. Staff #1 (S1) indicated Administrators and Leads handle the destruction of medication, it is documented in the binder, and taken back to the pharmacy. Interview with Staff #2 (S2) indicated medication is stored in locked cabinet until it is destroyed. S2 indicated staff has tried to send medication to the pharmacy but the pharmacy sends it back. Interview with Staff #3 (S3) indicated Administrators handle the destruction of medication; however, MedTechs will document it, inform the Administrators, and place the medicine back into the container.
Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20260408093853

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: 04/15/2026

NARRATIVE

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Regarding the allegation, “Staff did not follow required medication destruction procedures, ” based on record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of corrections developed, and a hard copy with appeal rights was provided to McKenzie Haulcy.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20260408093853

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: 04/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/01/2026 Section Cited CCR 80075(b)	1 2 3 4 5 6 7	(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by: Based on record review and observation, Medication Administration Record (MAR)	1 2 3 4 5 6 7	The Administrator will provide a plan of correction (POC) that includes how staff will ensure clients receive their medication as prescribed and that it documented accurately on the MAR. POC to be emailed to regina.cloyd@dss.ca.gov by the POC due date.
	8 9 10 11 12 13 14	(April 2026) revealed Client #3 (C3) received Pantoprazole Sod Dr 40 MG from 04/01/26 – 04/15/26 AM. LPA observed Pantoprazole Sod Dr 40 MG in the bubble packet for 04/07/26. This poses a potential risk to client in care.	8 9 10 11 12 13 14
Type B 05/01/2026 Section Cited CCR 80075(l)(1)	1 2 3 4 5 6 7	(l) Prescription medications ... which are not to be retained shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a client. (1) Both shall sign a record, ... This requirement was not met as evidence by:	1 2 3 4 5 6 7	The Administrator will provide proof of correction (POC) that includes how the facility will ensure medication is destroyed by administrator/staff and a witness and that the destruction logs is signed by both individuals. POC to be emailed to regina.cloyd@dss.ca.gov by the due date.
	8 9 10 11 12 13 14	Based on record review, Client #1, #2, and #4’s Centrally Stored Medication and Destruction Record(s) is missing 1 – 2 signatures. This poses a potential health, safety, and personal rights risk to clients in care.	8 9 10 11 12 13 14

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: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4