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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601898
Report Date: 05/17/2023
Date Signed: 05/23/2023 08:53:58 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230512153745
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:
05/17/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Anne Miranda - AdministratorTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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Facility is allowing unqualified staff to provide care and supervision to residents in care.
INVESTIGATION FINDINGS:
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On 05/17/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit in order to acquire investigation findings for the above allegation. LPA confirmed there was no tranfer request submitted prior to S2 and S3 working at the above mentioned facility. During today’s visit LPA met with Anne Miranda, Administrator (S1) and the purpose of the visit was explained.

The investigation consisted of the following: On 5/17/23 LPA met with staff #4 and toured the facility. LPA conducted interviews with Administrator and Staff Members #4-#6 and Residents #1-#6. LPA obtained and reviewed Staff and Residents roster, resident's medical assessments, their Needs and Services Plan (LIC625). LPA also obtained copies of the facilities' communication log .

LIC 9099C is on the next page.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 5
Control Number 11-AS-20230512153745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2023
NARRATIVE
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The investigation revealed the following:

Allegation: Facility is allowing unqualified staff to provide care and supervision to residents in care.

It was alleged that the Licensee, Mark Cummings, has been hiring underqualified staff without conducting background checks. On 5/17/23 LPA conducted interviews with the Administrator Anna Miranda, Staff #4-#6 (S4-S6) and Residents #1-6 (R1-R6). On 5/17/23 LPA conducted record reviews that confirmed that S2-S3 had not been associated with the above mentioned facility. During an interview conducted with Staff #1 (S1), it has been confirmed that S2 and S3 have been present at the facility and have been providing care to residents. According to the communication logs, there was additional proof of sufficient evidence to support that above mentioned allegation has taken place.

Based on the Documents, interviews conducted with administrator and a review of the facility’s communication log, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, Title 22 Division (6) has been cited on the attached LIC9099-D.

Exit interview was conducted and a copy of the report was provided to S1, administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230512153745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2023
Section Cited
CCR
87355(e)(2)
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(e) All individuals subject to a criminal record review..shall prior to working...in a licensed facility:
(2)Request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement was not met as evidenced by:
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LPA and Administrator have agreed that the transfer request for two staff members (S2-S3) will have been submitted on, or prior to, the POC due date to Mario.Leon@dss.ca.gov by means of either scanned documentation/photo evidence (via certified mail) or screenshot (via guardian).
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Evidence obtained through LPA observation, record review and interview with staff #1 (S1).

This poses a potential health and safety risk to all residents in care.
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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.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230512153745

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:
05/17/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Anne Miranda - AdministratorTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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9
Residents sustained unexplained injuries while in care.
Staff inappropriately touched residents in care.
INVESTIGATION FINDINGS:
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On 05/17/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit in order to acquire investigation findings for the above allegation. LPA confirmed there was no evidence found to support the above allegations. During today’s visit LPA met with Anne Miranda, Administrator (S1) and the purpose of the visit was explained.

The investigation consisted of the following: On 5/17/23 LPA met with staff #4 and toured the facility. LPA conducted interviews with Administrator and Staff Members #4-#6 and Residents #1-#6. LPA obtained and reviewed Staff and Residents roster, resident's medical assessments, their Needs and Services Plan (LIC625). LPA also obtained copies of the facilities' communication log .

SEE LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230512153745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2023
NARRATIVE
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The investigation revealed the following:

Allegations:

Residents sustained unexplained injuries while in care.

Staff inappropriately touched residents in care.



It has been alleged that a resident had experienced the above mentioned allegations. On 5/17/23 LPA conducted interviews with the Administrator Anna Miranda, Staff #4-#6 (S4-S6) and Residents #1-6 (R1-R6). On 5/17/23 LPA conducted record reviews of R1-R6 and interviews with S1, S4-S6 regarding the allegations listed above. Five out of Six residents (R2-R6) denied the allegations, while R1 was unresponsive. All staff members S1, S4-S6 have also denied the allegations. Therefore, there was not sufficient evidence to support that the above mentioned allegations had taken place.

Based on documentation, record reviews and interviews conducted, LPA did not observe sufficient evidence to support the above allegations, therefore the above allegations are unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5