198602612-12-21-2023-11-AS-MVAO-CZCT2X-20240110132127

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602612
Report Date: 12/21/2023
Date Signed: 12/21/2023 12:40:38 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2023 and conducted by Evaluator Lourdes Montoya

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231218111529

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: 10	DATE:	12/21/2023
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Hennessy Hernandez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On 12/21/2023 at 9:59 AM, Licensing program analyst (LPA) Lourdes Montoya conducted an initial 10-day complaint visit to this facility to investigate the allegation mentioned above. LPA met with Administrator Hennessy Hernandez and LPA explained the purpose of today’s visit. LPA observed ten residents, four staff and a health practitioner present during the visit.

The investigation consisted of the following: LPA Montoya toured the facility with Administrator Hernandez. LPA obtained copies of the following: Staff roster, resident roster and R1’s service records which include Identification and Emergency Information, Physician’s Report, Appraisal/Needs and Services Plan and other pertinent records. LPA interviewed four out of four staff (S1-S4), seven out of ten residents and one witness (W1) at the facility. Three residents were sleeping during the visit and LPA was unable to obtain statements from them. LPA attempted to interview one witness via telephone.

REPORT CONTINUED IN LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231218111529

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LUCERNE ONE LLC	FACILITY NUMBER: 198602612
	VISIT DATE: 12/21/2023

NARRATIVE

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Investigations Revealed the following:

Allegation: Staff does not treat resident with dignity and respect.

Soc 341 shows “Older Adult claims facility doesn't treat resident right".

It is alleged that staff does not treat resident with dignity and respect. On 12/21/2023 from 10:05 am to 12:05 pm, LPA Lourdes Montoya conducted interviews with staff, residents, and a witness. LPA interviewed four out of four staff (S1-S4), seven out of ten residents (R1-R7) and a witness present during the visit. S1 and S2 stated on December 18, 2023, R1 had a misunderstanding with R2 and S2 intervened but R1 did not complain about staff being disrespectful. S2 stated S2 apologized to R1 and R1 also apologized to S2 for the misunderstanding. Interview with R1 revealed facility staff are nice, respectful, and responsive. Based on interviews conducted, four staff (S1-S4), seven (R1-R7) and one witness (W1) denied the allegation that staff does not treat resident with dignity and respect. Based on LPA’s observations, all residents (R1-R7) are treated with dignity and respect by staff. All residents (R1-R7) commented that staff are kind, respectful and attentive to their needs.

Based on the record reviews and interviews conducted, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited during this visit.

An exit interview was conducted with Administrator Hennessy Hernandez and a copy of the report was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes Montoya	TELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023

LIC9099 (FAS) - (06/04)

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