198601543-6-14-2023-11-AS-MVAO-CUDV93-20230804161336

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601543
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:02:00 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
06/05/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230605081919

FACILITY NAME:	LUMIERE VILLA INC		FACILITY NUMBER:	198601543
ADMINISTRATOR:	NOLASCO MARASIGAN		FACILITY TYPE:	735
ADDRESS:	4167 W 168TH STREET		TELEPHONE:	(310) 465-7010
CITY:	LAWNDALE	STATE: CA	ZIP CODE:	90260
CAPACITY:	4	CENSUS:	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff preventing home health agency from treating resident

INVESTIGATION FINDINGS:

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On 06/14/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an initial 10-day complaint visit to investigate the allegation listed above. LPA Gibbs met with Staff, Meera Gopy and explained the purpose of today’s visit.

The investigation consisted of the following: LPA reviewed and received copies of Client’s (C1) Incident Report, hospital Discharge Paperwork, C1’s referral for Physical Therapy, recent Individual Program Plan (IPP), LPA interviewed staff (S1 and S2), C1’s mother, service provider (SP), and attempted to interview C1, and LPA toured the facility.

CONT ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230605081919

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: 06/14/2023

NARRATIVE

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Allegation: Staff preventing home health agency from treating resident

The investigation revealed the following: It is alleged facility staff is preventing C1 from receiving required Home Health Care and Physical Therapy ordered from Little Company of Mary Hospital. During interview with staff (S1 and S2), they stated Home Health Care did not contact the facility until 05/19/23 (5 weeks after C1 was discharged from LCOM) and when asked about Home Health Care they said C1 no longer requires 24-hour Home Health Care and misunderstood it also included Physical Therapy. S1 stated it was not intentional to deny all services. During interview with SP from Gibraltar Home Health Services, SP stated it was a misunderstanding communicating with the facility and closed all services. During interview with C1’s mother and S1 a referral has been sent for C1 to receive Physical Therapy.

Based on the record reviews and interviews conducted, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited during this visit. An exit interview was conducted with Meera Gopy, and a copy of the report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC9099 (FAS) - (06/04)

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