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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601898
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:55:20 PM


Document Has Been Signed on 09/08/2023 12:55 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:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:TIME COMPLETED:
01:00 PM
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On 9/8/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Mark Cumming /Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) residents ages 60 and above of which (4) may be non-ambulatory and (2) Bedridden in room #2 and #4. Facility has an approved hospice waiver for (6) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of (6) resident bedrooms, (4) resident bathrooms, (1) staff bathroom, living room, entertainment room, dining room, and kitchen gated pool.

LPA Iniguez toured the physical plant with administrator. There were no obstructions on the premises. A locked gate around the pool was observed and to access the pool, a locked door needs to be open. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 105.6°F, Bathroom #1:106.9°F and Bathroom #2:107.8°F

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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: 09/08/2023
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Medication Administration Records (MAR) were maintained in order. First AID kit was checked. Last facility disaster drill was on:8/16/2023. A copy of the liability insurance was provided to LPA during visit. LPA observed the facility's infection control practices.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Mark Cumming/Licensee.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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