<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601898
Report Date: 11/24/2021
Date Signed: 11/24/2021 12:09:36 PM

Document Has Been Signed on 11/24/2021 12:09 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:LADERA VISTAFACILITY NUMBER:
198601898
ADMINISTRATOR:MARK STEVEN CUMMINGSFACILITY TYPE:
740
ADDRESS:6502 SOUTH SHERBOURNE DRIVETELEPHONE:
(310) 216-9577
CITY:LOS ANGELESSTATE: CAZIP CODE:
90056
CAPACITY: 6CENSUS: 4DATE:
11/24/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Anna Miranda TIME COMPLETED:
01:30 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 11/24/2021, Licensing Program Analyst (LPA) Ngozi Nwaokoro conducted an unannounced visit to Ladera Vista and met with the Administrator Anna Miranda. The purpose of today’s visit was explained, to conduct the annual inspection with emphasis on Infection Control. Facility is licensed for six (6) residents, four ( 4) non- ambulatory residents and one (1) bedridden with approval for hospices waivers for six (6) residents. The facility currently has four (4) residents, some of the residents are receiving home health or hospice services. The facility does not handle any of the residents’ money.

LPA Ngozi and Anna Miranda toured the physical plant, checked food service, medications, reviewed staff records and reviewed resident files for medical status and first Aid kit. The facility conducted last fire drill September 25, 2021. The home consists of 4 resident bedrooms, 1 staff bedroom, 2 resident bathrooms, 1 staff bathroom, living room, entertainment room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid tile was in place. LPA measured water at 113.0 degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All doors have auditory alarms.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. Outside grounds were toured. In ground pool observed with gate around it. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report was given to Anna Miranda.

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Ngozi Nwaokoro
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3