198602612-4-30-2023-11-AS-PBUR-CRE6GD-20230430204747

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602612
Report Date: 04/21/2023
Date Signed: 04/30/2023 08:48:52 PM

Document Has Been Signed on 04/30/2023 08:48 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, 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:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Estelle Lewis and Hennessy Hernandez		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	Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms, and LPA temperature was checked. LPA Bunker met with the Director of Operation Estelle Lewis and Administrator Hennessy Hernandez and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. The facility is licensed as Residential Care Facility for the Elderly (RCFEs) to serve residents ages 60 and older. There are currently eleven (11) residents in placement. The facility's annual fees are current. The following 11 Domain will be observed and reviewed: Infection Control, Physical Plant & Environmental, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Rights-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, and Disaster Preparedness "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a two-story-family home located in a residential neighborhood. Director of Operation Estelle, Administrator Hennessy, and LPA Bunker toured the facility, which consisted of the following: Living room, 2 offices, kitchen, dining room, 10 bedrooms, 11 bathrooms, family room, beauty salon, spa room, employee lounge, laundry room, family lounge/gym/physical therapy room, shaded patio area, indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: LUCERNE ONE LLC	FACILITY NUMBER: 198602612
	VISIT DATE: 04/21/2023

NARRATIVE

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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked, and records are current. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 118 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on April 03, 2023

There were no deficiencies cited.

Due to time constraints, LPA Bunker was unable to complete the visit and will return back at a later date to complete the visit.

Exit interview conducted.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Pamela Bunker	TELEPHONE: (323) 213-1113
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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