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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602612
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:15:42 PM


Document Has Been Signed on 06/21/2024 03:15 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



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: 11DATE:
06/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Assistant to Owner - Michael SaucedoTIME COMPLETED:
03:20 PM
NARRATIVE
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On 6/21/2024 around 1:20 PM LPA Leandro arrived at Lucerne One LLC. LPA was met with Michael Saucedo and explained the purpose of the visit.

LPA and a staff completed a tour of the facility. LPA observed a washer and dryer in disrepair. Staff informed LPA that there is currently no administrator in the facility.

Deficiencies are being cited based on LPA observation and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding Administrator Qualifications and Maintenance and Operation.

An exit interview was conducted and a copy of this report and appeal rights were discussed and left with Michael Saucedo.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/21/2024 03:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87405(a)

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87405(a) Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require...written documentation.
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The licensee will hire a certified administrator and email proof of correction to Socorro.Leandro@dss.ca.gov and Ulysses.Coronel@dss.ca.gov.
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This requirement is not met as evidence by:

Based on interviews conducted there is no current administrator in the facility.
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Type B
06/28/2024
Section Cited
CCR87303(a)

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87303(a) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The licensee will fix the washer and dryer and email proof of correction to Socorro.Leandro@dss.ca.gov and Ulysses.Coronel@dss.ca.gov.
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This requirement is not met as evidence by:

Based on interviews and observation there is a washer and dryer in disrepair.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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