<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602612
Report Date: 09/12/2024
Date Signed: 09/27/2024 10:15:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2024 and conducted by Evaluator Socorro Leandro
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240718143650
FACILITY NAME:LUCERNE ONE LLCFACILITY NUMBER:
198602612
ADMINISTRATOR:ESTELLE LEWISFACILITY TYPE:
740
ADDRESS:11235 & 11237 LUCERNE AVETELEPHONE:
(310) 390-8181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90230
CAPACITY:15CENSUS: 1DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator - Karen GaytanTIME COMPLETED:
12:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff inappropriately touched a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This is an amendment of the report dated 09/12/2024, the reason for the amendment is to remove personal information of Resident 1 (R1).*

On 09/12/2024 around 12:00 PM Licensing Program Analyst (LPA) Leandro conducted an unannounced, continuation complaint visit to the above-mentioned facility. LPA was met by Administrator Karen Gaytan and explained the purpose of the visit.
The investigation consisted of the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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 2
Control Number 11-AS-20240718143650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: LUCERNE ONE LLC
FACILITY NUMBER: 198602612
VISIT DATE: 09/12/2024
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
26
27
28
29
30
31
32
*This is an amendment of the report dated 09/12/2024, the reason for the amendment is to remove personal information of Resident 1 (R1).*

On 07/22/2024, LPA Leandro received facility records such as Timesheets, Personnel Record, Resident Census, Unusual Incident Reports, and Resident 1’s (R1) Records.
On 09/02/2024, Community Care Licensing Division (CCLD), Investigation Brach (IB), Investigator Garcia completed the CCLD IB Investigation Assignment Report.
On 09/10/2024 and 09/12/2024, LPA Leandro reviewed the CCLD IB Investigation Assignment Report which consisted of Facility Records, Resident 1’s Records, and interviews conducted.

The investigation revealed the following: Regarding the allegation “Staff inappropriately touched a resident,” it is being alleged that a staff member touched R1 in their private area. Record review of the CCLD IB Investigation Assignment Report indicates the following: Investigator Garcia interviewed a total of 7 individuals. 4 out of 7 individuals indicate that this is a false allegation. 3 out of 7 individuals “could not confirm nor deny the allegation” and/or were “not certain if the allegation was credible.” Investigator Garcia was unable to interview R1 due to refusal of interview. Regarding the allegation, “Staff inappropriately touched a resident", the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred, therefore the allegation is unsubstantiated.

No deficiencies were cited. An exit interview was conducted, and a copy of the Complaint Report was provided to the Administrator.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2