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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602612
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:32:39 PM


Document Has Been Signed on 09/06/2024 02:32 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:KAREN GAYTANFACILITY TYPE:
740
ADDRESS:11235 & 11237 LUCERNE AVETELEPHONE:
(310) 390-8181
CITY:LOS ANGELESSTATE: CAZIP CODE:
90230
CAPACITY:15CENSUS: 1DATE:
09/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:ADMINISTRATOR KAREN GAYTANTIME COMPLETED:
02:30 PM
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On 09/06/2024 around 12 noon Licensing Program Analyst (LPA) Jose Calderon initiated an announced Case Management - Other to Lucerne One LLC Technical Assistance to the above said facility.

LPA Calderon was given a tour of the facility's main building by Administrator Karen Gaytan. The tour consisted of a two-story residential home, all common areas which included but were not limited to, 10 bedrooms and 10 bathrooms and patio area. LPA Calderon noted 1 resident still living at the facility in room #4. LPA Calderon checked all 10 rooms and noted 9 out of 10 rooms were vacant with no beds o residents’ clothes. LPA Calderon noted 3 staff working, running water, AC was working. Kitchen functioned and had food and water to drink in the refrigerator. There was power to the building and TV was working.

LPA Calderon also requested copies of the facility's line list with date of discharge, contact information to new placement locations, submit closure plan. LPA Calderon conducted an interview with Administrator Karen Gaytan. Administrator Karen Gaytan was advised to submit closure plan, stop accepting new residents and entering into a new admission agreement for new residents. To send a copy of the closure plan to the local ombudsman program and to maintain compliance with Title 22 Regulations. The Administrator Karen Gaytan will provide updated line list and relocation information for residents by hand to LPA Calderon.

An exit interview was conducted with Administrator Karen Gaytan and a hard copy was provided by hand for signature.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
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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