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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601543
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:10:18 PM

Document Has Been Signed on 06/28/2023 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:LUMIERE VILLA INCFACILITY NUMBER:
198601543
ADMINISTRATOR:NOLASCO MARASIGANFACILITY TYPE:
735
ADDRESS:4167 W 168TH STREETTELEPHONE:
(310) 465-7010
CITY:LAWNDALESTATE: CAZIP CODE:
90260
CAPACITY: 4CENSUS: 2DATE:
06/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rishideosi Mohabeer Care GiverTIME COMPLETED:
03:32 PM
NARRATIVE
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On 06/28/2023, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA)Antonine Richard, conducted an unannounced case management - deficiencies visit to Lumiere Villa Inc., to document deficiencies observed during the investigation of the complaint with complaint control number 11-AS-20230622140759. LPM Coronel and LPA Richard met with Rishideosi Mohabeer Staff, and explained the reason for the visit.

During todays visit LPM and LPA observed the following inside the facility: 2 cans of disinfectants and a box of drill bits by the front door living area, half a gallon of expired orange juice under the kitchen sink, 5 cans of spray paint and sewing scissors in the living drawer, accessible to clients in care.

The facility staff stated that they were in the process of doing spring cleaning outdoors, where LPA and LPM observed the presence of gardening tools such as shovels and trowels, pesticides, a knife, a fully charged LPG fuel tank, 2 cans of paint and a gallon bottle of vehicle anti freeze coolant.

Title 22 Division 6 Chapter 1 is bing cited, please see LIC809D.

An exit interview was conducted and plans of corrections were developed with the licensee. A copy of the report and appeals rights were provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/28/2023 03:10 PM - It Cannot Be Edited


Created By: Antonine Richard On 06/28/2023 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2023
Section Cited
CCR
80087(g)

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Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients..
These requirements was not met as evidenced by:
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The licensee agreed to store the said items locked and inaccessible to clients in care. Staff taining will be conducted to ensure future compliance with Title 22 regulation 80087(g). Proof of correction will be submitted to LPA Richard.
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Based on LPM and LPA observations, Disinfectants, cleaning solutions, poisons, and other items that could pose a danger are stored where accessible to clients, which poses a potential health and safety and personal rights risk to clients 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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Antonine Richard
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2023


LIC809 (FAS) - (06/04)
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