198601898-8-31-2024-11-AS-SLEO-D8NPTE-20240831113550

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601898
Report Date: 08/31/2024
Date Signed: 08/31/2024 11:35:59 AM

Document Has Been Signed on 08/31/2024 11:35 AM - 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:	LADERA VISTA		FACILITY NUMBER:	198601898
ADMINISTRATOR/ DIRECTOR:	MARK STEVEN CUMMINGS		FACILITY TYPE:	740
ADDRESS:	6502 SOUTH SHERBOURNE DRIVE		TELEPHONE:	(310) 216-9577
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY: 6		CENSUS: 6	DATE:	08/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Licensee/Administrator, Mark Steven Cummings		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 08/31/2024 at around 8:50 AM, Licensing Program Analyst (LPA) Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee/Administrator, Mark Steven Cummings. LPA explained the purpose of the visit and was accompanied by a staff member inside and outside the facility during this inspection. This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden and 4 maybe on hospice. A total of 6 residents are currently residing in this facility. The Annual Licensing Fees are current. The facility is a one-story house located in a residential street. The home consists of 6 resident bedrooms, 3 full bathrooms, 1 toilet room, 1 kitchen/living room area, 1 laundry room, 1 office room, 1 backyard patio area with shaded seating, 1 indoor/outdoor patio area with shaded seating, and 1 attached garage.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024

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: LADERA VISTA	FACILITY NUMBER: 198601898
	VISIT DATE: 08/31/2024

NARRATIVE

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Outside grounds were toured and no bodies of water were observed. The patio furniture is under a shaded area and accessible to residents. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

LPA toured the kitchen area and observed supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxics were kept in locked storage cabinet.

LPA observed that medications were safe, locked, and inaccessible. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. Documents are posted as mandated. Last Disaster and Fire drill was conducted on 08/15/2024. First aid kit is fully stocked. Smoke and carbon monoxide detectors were in compliance and operational. There is a fire extinguisher in the kitchen area. There is a videoconferencing device dedicated for client use in the kitchen area.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024

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: LADERA VISTA	FACILITY NUMBER: 198601898
	VISIT DATE: 08/31/2024

NARRATIVE

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6 out of 6 resident’s bedrooms were checked. Mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathroom toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature and it measured between 105 and 120 degrees Fahrenheit. This facility provides residents with hygiene products such as feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

5 staff records were reviewed, 5 out of 5 staff records had required documentation.
5 resident records were reviewed and, 5 out of 5 resident records had required documentation.

No deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22.

An exit interview was conducted, and a copy of this report was left with the Licensee.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2024

LIC809 (FAS) - (06/04)

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