198601543-3-18-2022-11-AS-JCAS-CCMUBX-20220318152703

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601543
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:27:24 PM

Document Has Been Signed on 03/18/2022 03:27 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

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:	03/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Meera Gopy		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas met with staff, Rishi Mohabeer and conducted a risk assessment, based on the assessment, the facility is clear of Covid-19 infection. the purpose of todays visit was explained. The facility is licensed for four (4) ambulatory client and prefers to serve developmentally disabled adults ages 18 thru 59 years. LPA was granted access and allowed to enter the facility to conduct inspections.

LPA, Gopy, and Mohabeer toured the inside and outside grounds of the facility. The one story residential house consists of three (3) bedrooms, two (2) bathrooms, tv room/office, living room, kitchen, dining room, shaded backyard, indoor and outdoor activity area, laundry area, unattached garage. Outdoor and indoor passageways are kept free of obstruction.

During the tour, LPA observed the facility’s infection control practices. LPA verified that the facility has an approved mitigation plan report. LPA was properly screened for Covid-19 symptoms, temperature was checked and documented. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, PPE supplies are readily available to staff, and an additional 30 day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. LPA observed all staff wear a face covering. LPA observed required postings throughout the facility.

All rooms were inspected, Bedroom #1 and #2 are designated for clients and contain furniture and lighting fixtures as mandated, bedroom #3 is being used as storage, bedrooms are private, one client per room. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed.

Resident bathroom was checked, bathroom#2 is inside bedroom#3 sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the water temperature measured at 107.8 degrees F in bathroom. Comfortable temperature was maintained in the facility.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: LUMIERE VILLA INC	FACILITY NUMBER: 198601543
	VISIT DATE: 03/18/2022

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LPA toured the kitchen area Knives are locked and inaccessible in kitchen drawer. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to clients in care. One (1)Carbon Monoxide and interconnected Smoke Detectors tested, and in operating condition. The facility has one (1) Fire Extinguisher, which was checked and found to be fully charged, accessible, and purchased receipt dated 09/30/2021 available. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Outside grounds were toured, . On 3/18/2022 LPA observed a hand held spray paint bottle an insect killing spray bottle in the backyard area. No bodies of water were observed. Common areas were clean and clear; doorways were free of obstructions. No bodies of water present.

Advisory Notes with technical assistance were issued:

1. Ensure all staff is fit tested for respirator masks.

A deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided to facility representative.

SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Jey Cardenas
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/18/2022 03:27 PM - It Cannot Be Edited

Created By: Jey Cardenas On 03/18/2022 at 02:00 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
MONTERY PARK, CA 91754

FACILITY NAME: LUMIERE VILLA INC	FACILITY NUMBER: 198601543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

This requirement is not met as evidenced by: Disinfectants, cleaning solutions, poisons, firearms and other items that could pose..
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above; LPA Observed spray paint bottle and insect killing spray accessible to clients in the backyard which poses an immediate health, safety risk to persons in care.
	POC Due Date: 03/19/2022
	Plan of Correction
1 2 3 4	The two bottles (spray paint and killing spary) were removed at the time of visit, deficiency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Angela J Kendrick

LICENSING EVALUATOR NAME:

Jey Cardenas

LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022

LIC809 (FAS) - (06/04)

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