198602612-3-9-2022-11-AS-GJON-CCCVSN-20220309154149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602612
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:41:58 PM

Document Has Been Signed on 03/09/2022 03:41 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
MONTEREY PARK, CA 91754

FACILITY NAME:	LUCERNE ONE LLC		FACILITY NUMBER:	198602612
ADMINISTRATOR:	ESTELLE LEWIS		FACILITY TYPE:	740
ADDRESS:	11235 & 11237 LUCERNE AVE		TELEPHONE:	(310) 390-8181
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90230
CAPACITY:	15	CENSUS: 11	DATE:	03/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Estella Lewis		TIME COMPLETED:	04:00 PM

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	03/09/22, Licensing Program Analysts (LPA) Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA Johnson met with the Administrator Estella Lewis. LPA Johnson explained the purpose of today’s visit. The facility is licensed to operate and care for thirteen (13) non-ambulatory adults (ages 60 and over, two (2) of which may be bedridden. Currently, 11 residents reside at this facility. Facility Structure The facility is a two-story structure located in a residential neighborhood. It consists of the following: ten (10) bedrooms with bathrooms in each room (no live in staff), three (3) bathrooms (available for all to use) living area, family room with physical therapy, dining area, kitchen, beauty area room, spa room, and outdoor recreational activity area and outside patio. Bedrooms (Client rooms) There are eight (8) private bedrooms and two shared bedrooms (one (1) shared bedroom on each floor). All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided in each room. Storage for client personal belongings was observed. Physical Plant LPA Johnson toured the physical plant. There were no bodies of water or obstructions on the premises. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 108.6 degrees F. Storage & Inaccessible Items Storage areas for personal hygiene, medications, cleaning supplies, toxins, and sharp objects were stored, locked and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and maintained properly. Smoke detectors and carbon monoxide detectors were operable. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers are posted and readily available for review near the dining table. Facility has a land line telephone located in living room. Four (4) fire extinguishers (two (2) downstairs, one (1) upstairs and one (1) outside in the family/physical therapy room were fully charged. Menu posted in the kitchen. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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
MONTEREY PARK, CA 91754

FACILITY NAME: LUCERNE ONE LLC	FACILITY NUMBER: 198602612
	VISIT DATE: 03/09/2022

NARRATIVE

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Infection Control
During the visit, LPA Johnson observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. Sanitizing stations in common areas and restrooms. LPA Johnson observed staff was wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs were reviewed. The facility has a Mitigation Plan Report approved by CCLD on file.

No deficiencies were cited during this inspection visit.

An exit interview was conducted with Estella Lewis. A copy of this report was printed and provided to Estella Lewis.

End of report

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Gail Johnson	TELEPHONE: (626) 228-4917
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC809 (FAS) - (06/04)

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