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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601898
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:10:08 PM


Document Has Been Signed on 11/02/2022 03:10 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, 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: 6DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Mark Cummings - Licensee/AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mario Leon conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Mark Cummings and the purpose of today’s visit was explained.

The home consists of 6 resident bedrooms, 3 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 mat was in place. LPA measured water temperature in bathroom #1 at 112.6 F, bathroom #2 at 113.1 F and kitchen at 116.0 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. All doors have auditory alarms, unused (depending on census).

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 was observed with gate around it. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

See LIC809C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LADERA VISTA
FACILITY NUMBER: 198601898
VISIT DATE: 11/02/2022
NARRATIVE
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LPA advised the licensee to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

There was one (1) citation during this visit, see 809D. Technical Assistance was provided, see LIC9102.

Exit interview conducted and a copy of this report was given to Mark Cummings, Licensee/Administrator.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/02/2022 03:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: LADERA VISTA

FACILITY NUMBER: 198601898

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Licensing Program Analyst Leon's observation, the licensee did not comply with the section cited above in 87309(a)(1) as paints, one (1) saw and two (2) pair of shears were accessible to clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2022
Plan of Correction
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Licensee will provide images via email at mario.leon@dss.ca.gov within the next week
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4