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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602612
Report Date: 03/19/2024
Date Signed: 03/19/2024 12:43:57 PM


Document Has Been Signed on 03/19/2024 12:43 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hennessy HernadezTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the Annual inspection. LPA met with Hennessy Hernandez , Administrator and the purpose of the visit was discussed. Facility is licensed to serve 15 elderly ages 60 and over, 13 non ambulatory and 2 bedridden with a hospice waiver for 6. The facility does not handle any of the residents’ money. Currently there are 11 residents in placement.

This home is a two story home consisting of: (10) resident bedrooms, (10) Full bathroom, 1 half restroom for guest, dining area, kitchen and living room area/ den in the rear of the home. There are stairs to the 2nd floor or a elevator. There are 5 rooms upstairs and 5 rooms downstairs. There is a separate detached part of the home in the rear considered 11235 in which there is 2 bedrooms, family room, gym and 2 bathroom. The bedrooms at 11235 are not occupied at time of visit. The laundry room is attached to 11235. There is a shaded patio area upstairs and downstairs of the facility. LPA toured all resident bedrooms and observed all the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 110 and 112. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

No Deficiencies were observed during this visit

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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