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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602612
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:36:33 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
06/24/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20240624161624
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:
07/03/2024
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:STAFF MICHAEL SAUCEDOTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not assist resident in a timely manner.
INVESTIGATION FINDINGS:
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On 07/03/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Lucerne One LLC and was greeted by Staff Michael Saucedo S1. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed staff S1-S4 and interview clients R1-R5. LPA Calderon interviewed W1-W2. On 07/03/2024 LPA Calderon obtained and reviewed the following: Incident report (date 06/23/2024), Admission agreement (date 08/22/2019) for R2, Physician Report (date 11/24/2023).for R2.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
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-20240624161624
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: 07/03/2024
NARRATIVE
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Regarding Allegation #1: Staff did not assist resident in a timely manner. It is being alleged that staff did not assist R1 in the dining room in a timely manner. The interviews indicate: S1 indicates that S1 staff are trained to take care of residents needs in a timely manner. S1 indicates that the facility does not keep call button log notes but on average staff takes 5 to 10 minutes to respond to a resident pushing the call button. 3 out of 3 staff indicate that when a call button is pushed by a resident it takes 5 to 10 minutes for staff to respond and take care of the resident’s needs. R1 indicates that R1 has no issues with staff taking care of R1 needs and R1 never made a complaint for staff not responding in a timely manner. R2-R3 indicate that when they press the call button it takes staff 10 minutes to respond and take care of their needs. R4-R5 could not answer any questions due to health issues. W2 indicates that R1 was in the dining room and staff did not respond to the call button within 30 minutes. W2 asked reporting party to check in on R1 and reporting party indicated to W2 that R1 advised reporting party that R1 was in the dining room and staff took 30 minutes to take care of R1 needs. Reviewed Physician Report (date 11/24/2023) for R1. R1 has cognitive issues.

Based on interviews, observations and supporting documents. The preponderance of evidence standard has NOT been met; therefore, the allegation of “Staff did not assist resident in a timely manner” is found to be UNSUBSTANTIATED.

A face-to-face meeting was conducted with Staff Michael Saucedo, and a hard copy was provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2