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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601543
Report Date: 08/13/2025
Date Signed: 08/13/2025 04:58:15 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250806092753
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: 1DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Meera Gopy, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests
Staff did not ensure food/hygiene products were not expired
Staff do not ensure the facility is clean and orderly
INVESTIGATION FINDINGS:
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On 8/13/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Meera Gopy and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:

On 8/13/25 LPA requested and reviewed copies of the following records: Client file, Resident Roster, Identification and Emergency Information, Admission Agreement, Physician’s Report, Last medical appointment document, last dental appointment document. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3. Client 1 was at his day program. LPA Shirley attempted to interview him and was not able to as he is non-verbal.

The investigation revealed the following:
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
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 6
Control Number 11-AS-20250806092753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543
VISIT DATE: 08/13/2025
NARRATIVE
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Allegation: Staff did not ensure the facility was free from pest

It is alleged that there is an infestation of cockroaches in C1’s personal belongings. On 8/13/25, LPA Felisa Shirley conducted a tour of this facility and an inspection of C1’s personal items. LPA Shirley inspected C1’s drawers and searched between articles of clothing and underwear and did not observe any live nor dead cockroaches. LPA Shirley inspected C1’s closet and inspected hanging items and shoes and did not observe live nor dead cockroaches. LPA Shirley inspected C1’s mattress which was enclosed in a mattress protection bag and did not see any live activity of bed bugs. LPA Shirley opened and closed drawers and closets observing for live activity. LPA inspected facilities rooms, bathrooms, kitchen, drawers, closets and windowsills and did not observe any live activity of pest.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. Client 1 (C-1), was not available for interview

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff did not ensure food/hygiene products were not expired

It is alleged that there are expired items of food and personal hygiene products not fit for consumption and personal care for residents in care. On 8/13/25, LPA Shirley conducted a tour of this facility and went into the kitchen to inspect the refrigerator and cabinets. During the tour, LPA Shirley observed that the refrigerator was adequately supplied and contained all the essential food items. During the inspection, LPA Shirley did not observe any expired items of food. During the inspection of cabinets, LPA observed that the can good were organized and the items with expiration dates nearing were located in the front of the cabinet for easy access to remove after expiration, as stated in an interview with S3. During interviews, the Administrator stated that she had recently bought groceries. LPA Shirley toured the bathroom and inspected C1’s personal hygiene items located in a container underneath the sink and did not observe any expired items.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20250806092753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543
VISIT DATE: 08/13/2025
NARRATIVE
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LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. Client 1 (C-1), was not available for interview

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

Allegation: Staff do not ensure the facility is clean and orderly

It is alleged that this facility had a cluttered and unclean environment. LPA Shirley toured the facility and observed that the administrator maximalizes the use of her space. Despite the abundance of possessions, everything had a designated place. During the tour, LPA Shirley did not have difficulty inspecting items and no issues with walkways. LPA Shirley did not observe any hazards or obstructions. LPA Shirley did advise the administrator to reduce excess items and to simplify her surroundings to make her space more functional.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. Client 1 (C-1), was not available for interview

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Meera Gopy.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250806092753

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: 1DATE:
08/13/2025
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Meera Gopy, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
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9
Staff do not ensure residents dental needs are met
INVESTIGATION FINDINGS:
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On 8/13/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Meera Gopy and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:

On 8/13/25 LPA requested and reviewed copies of the following records: Client file, Resident Roster, Identification and Emergency Information, Admission Agreement, Physician’s Report, Last medical appointment document, last dental appointment document. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff-3. Client 1 was at his day program. LPA Shirley attempted to interview him and was not able to as he is non-verbal.

The investigation revealed the following:
Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Citations on this Visit Report are Under Appeal!

Control Number 11-AS-20250806092753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
08/27/2025
Section Cited
CCR
85075(b)
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85075 Health-Related Services

(b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.

This requirement was not met as evidenced by:
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Licensee will review regulation and submit written proof of understanding of the regulation and submit proof of C1’s dental visit to LPA Shirley’s email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016 by POC due date of 8/27/25.
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Based on interviews and records reviewed, C1 has not been seen by a dentist since 10/21/23. Licensee violated this regulation by not ensuring clients dental health. This action poses as a potential health risk to persons 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20250806092753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543
VISIT DATE: 08/13/2025
NARRATIVE
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Allegation: Staff did not ensure resident’s dental needs were met

It is alleged that C1 is overdue for dental care. On 8/13/25, LPA Shirley reviewed C1’s Medication Administration Record, (MAR) and observed that it was organized and filled out appropriately. LPA Shirley reviewed medical, podiatry and dental records. C1’s last medical appointment was 7/30/24 and the next appointment is 8/25/25. The latest podiatry appointment was 4/21/25. C1’s last dental appointment was 10/21/23, per the receptionist at Lekavich Dental Corporation. Receptionist verified that C1’s next appointment is scheduled for 8/16/25.

LPA interviewed staff 1 – staff 3 (S-1 – S-3). Of those interviewed 3 out of 3 denied the allegation. Client 1 (C-1), was not available for interview

Based on observations, information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.



Based on CCLD staff's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6), is being cited, please see attached LIC-9099D.

Deficiency was cited for this allegation during today's visit.

An exit interview was conducted, and plans of corrections were developed with the Administrator, Meera Gopy. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6