198601543-2-1-2023-11-AS-JHAD-CPFTN4-20230227135208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601543
Report Date: 02/01/2023
Date Signed: 02/01/2023 12:30:38 PM

Unsubstantiated

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
05/03/2021 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210503150523

FACILITY NAME:	LUMIERE VILLA INC		FACILITY NUMBER:	198601543
ADMINISTRATOR:	NOLASCO MARASIGAN		FACILITY TYPE:	735
ADDRESS:	4167 W 168TH STREET		TELEPHONE:	(424) 247-9592
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY:	4	CENSUS: 2	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Subina Mohabeer		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not notice change in residents condition.
Staff did not notify Authorized Representative of injuries.
Staff did not notify authorized representative of residents medication change.

INVESTIGATION FINDINGS:

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On 12/09/2022 at 10:00am, Licensing Program Analyst (LPA) Perry Scott and Licensing Program Manager (LPM) Janae Hammond met with Licensee. The purpose of the visit was due to a complaint made against the facility.

The investigation consisted of the following: On 05/11/2021, LPA Troy Agard conducted the initial 10-day visit. LPA completed a walkthrough of the facility, interviewed Administrator, and requested copies of facility records: 1) Client roster, 2) Staff roster, 3) Physician reports, 4) Hospitalizations and 5) Incident Report, 6) Medication Admin Records 7).
On 9/01/2021 LPA Cardenas interviewed Administrator, (S1) Gopi Lilowtee regarding allegations. On 09/01/2021 LPA Cardenas tried to interview C1 and was unsuccessful due to communication barriers. On 10/20/2021 LPA Cardenas interviewed witness (W1). On 10/21/2021 LPA Cardenas interviewed witness (W2).
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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 3

Control Number 11-AS-20210503150523

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: LUMIERE VILLA INC	FACILITY NUMBER: 198601543
	VISIT DATE: 02/01/2023

NARRATIVE

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The investigation revealed the following: Regarding the allegation staff did not notice change in resident’s condition:
The department received a complaint alleging that C1's right ankle was swollen, and facility staff failed to notice. LPA interviewed W1 and W1 stated that C1 was admitted to the hospital and was diagnosed with cellulitis. LPA asked W2 is there any way of knowing how long before it developed? W1 responded that due to C1’s developmental delay, C1 couldn't say when it started, therefore it would be hard to determine. On 10/21/2021 LPA interviewed W2. W2 stated that on 05/01/2021 she discovered that C1's ankles were swollen when she was preparing C1 for bed. W2 also stated that when she picked up C1 from the facility, C1 did not show any signs of distress, no fever, and C1 was happy. C1 was limping, however. On 05/02/2021 W2 took C1 to get a pedicure. On 05/03/2021 W2 took C1 to the hospital and it was found that C1 had edema and cellulitis.
On 09/01/2021 LPA Cardenas interviewed the administrator. The administrator denied the allegation. When C1 was picked up, C1 did not have any swelling or redness. Additionally, the administrator stated that C1 has always had extremely dry skin. The administrator did a body check while bathing C1 the night before W2 picked C1 up and did not notice any concerns.

LPA attempted interview C1-C3 and was unsuccessful due to communication barriers. LPA reviewed all medical records from the hospital dated 05/03/2021 and 05/04/2021 which revealed C1 was diagnosed with edema and cellulitis. LPA reviewed facility records for C1 which included special incident reports, physicians’ reports, individual program plan, and facility notes. Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation of staff did not notice a change in residents’ condition is found to be unsubstantiated.

Regarding the allegation staff did not notify authorized representative of injuries. The department received a complaint that the authorized representative was not notified that C1’s right ankle was swollen. On 09/01/2021, LPA interviewed the administrator, and the administrator denied the allegation, stating that C1 did not have any swelling or redness before C1 left the night before (04/30/2021) to go with W2 for the weekend. The administrator did a body check and did not notice any concerns. If staff finds any injuries the authorized representative is notified via text. LPA attempted to interview C1-C3 and was unsuccessful due to communication barriers. LPA reviewed facility records for C1 which included: incident reports, physician’s records, and medication administration records.

Continued on LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210503150523

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: LUMIERE VILLA INC	FACILITY NUMBER: 198601543
	VISIT DATE: 02/01/2023

NARRATIVE

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Based on interviews conducted and records reviewed there was insufficient information to corroborate the allegation.

Regarding the allegation that staff did not notify authorized representative of resident’s medication change. On 10/21/2021 LPA interviewed W2 about C1’s medication. LPA asked, “does the facility call you to notify you of anything regarding condition? When did C1 start Prozac 20mg?”. W2 said it was unknown when the change occurred. They do not communicate with her and that they said that C1 is an adult and that C1 can make decisions. Based on interviews conducted and records reviewed there was insufficient information to corroborate the allegation.

Unsubstantiated: Although the allegation(s) 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.

An exit interview was conducted, and a copy of this report was given to Licensee, Subina Mohabeer.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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