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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601543
Report Date: 02/09/2024
Date Signed: 02/09/2024 04:10:17 PM

Document Has Been Signed on 02/09/2024 04:10 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Lillowtee GopyTIME COMPLETED:
04:30 PM
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On 02/09/24, Program Analyst (LPA) Antonine Richard 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 Richard 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 Richard and Administrator Gopy, and Mohabeer toured the inside and outside grounds of the facility. The one story residential house consists of three (3) bedrooms, two (1) bathrooms, tv room/office, living room, kitchen, dining room, shaded backyard, indoor and outdoor activity area, laundry area, unattached garage. LPA observed a locked gated pool. 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.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: LUMIERE VILLA INC
FACILITY NUMBER: 198601543
VISIT DATE: 02/09/2024
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 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, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the hot water temperature measured at 110.6F degrees F Comfortable temperature was maintained in the facility 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. The First Aid kit was available and fully stocked. There are no security bars or weapons on the premises.

Exit interview conducted. A copy of the report was provided to the administrator Gopy.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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