<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601543
Report Date: 06/28/2023
Date Signed: 06/28/2023 03:14:11 PM

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
06/22/2023 and conducted by Evaluator Antonine Richard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230622140759
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
UNANNOUNCEDTIME BEGAN:
08:03 AM
MET WITH:Rishideosi Mohabeer, Care GiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications are not properly destroyed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/28/2023, Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA)Antonine Richard, conducted an unannounced complaint visit to Lumiere Villa Inc. Regarding the above allegation. LPM Coronel and LPA Richard met with Rishideosi Mohabeer Staff, and explained the reason for the visit.

The investigation consisted of the following: During today's visit LPA interviewed 3 staff and 1
of 2 residents. LPA reviewed and obtained facility and clients records.

The investigation revealed the following: Record reviews indicate that the facility does not document the destruction of medications. Staff Interviews indicate that medications are being destroyed by taking them to the pharmacy for destruction. 3 out of 3 staff confirmed that destruction of medications are not recorded. During today's visit 1out of 2 client was interviewed but was not able to provide any answer. The second client was not available during today's visit.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20230622140759
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: 06/28/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Based on LPM and LPA interviews conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Title 22 Division 6 Chapter 1 is being cited, please see LIC9099D.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230622140759
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
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
80075(l)(1)(A-D)
1
2
3
4
5
6
7
Health-Related Services. Prescription... shall be destroyed by facility administrator...client. Both...a record, to be retained... lists the following: Name ...client. The prescription ... and the...pharmacy. The drug name... quantity destroyed. The date...
1
2
3
4
5
6
7
The licensee agreed to follow the facilities program plan regarding destruction of medications and will conduct staff training to ensure future compliance to Title 22 Regulation 80075(l)(1)(A-D). Proof of correction will be submitted to LPA Richard.
8
9
10
11
12
13
14
Based on observation, record review and interviews conducted. The licensee failed to ensure that records of destroyed medications are retained for at least one year, which poses a potential health and safety and personal rights risk to clients in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3