197608567-7-24-2023-11-AS-PSCT-CU2SAS-20230724134249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608567
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:42:53 PM

Document Has Been Signed on 07/24/2023 01:42 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	CHARNOCK RESIDENTIAL HOME		FACILITY NUMBER:	197608567
ADMINISTRATOR:	HILDA CERVANTES		FACILITY TYPE:	740
ADDRESS:	11172 CHARNOCK ROAD		TELEPHONE:	(310) 991-8120
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90034
CAPACITY:	4	CENSUS: 4	DATE:	07/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Hilda Cervantes		TIME COMPLETED:	02:00 PM

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On 7/24/2023, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with Administrator, Hilda Cervantes, and explained the purpose of today’s visit. The facility is licensed to operate for (4) non-ambulatory elderly residents ages 60 and above; and has a hospice waiver for two (2). Currently, the home has (3) clients in placement, and all are non-ambulatory. None of the clients have Restricted Health Care Conditions and none are utilizing postural supports or protective devices. The facilities annual fees are current.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: two resident bedrooms, one bathroom, kitchen and dining area, office area, laundry room, with two car attached garage and outside covered area.

LPA conducted a records review of (3) client records, (6) staff records, and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit. Liability insurance was in effect at the time of the visit.

LPA and administrator toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 106.6F. A comfortable temperature is maintained in the facility.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable food available which is stored properly. Fire extinguisher was charged, smoke detectors and Carbon Monoxide were operable. The last fire/emergency drill was conducted on 02/03/2023.

Report continued on LIC809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHARNOCK RESIDENTIAL HOME	FACILITY NUMBER: 197608567
	VISIT DATE: 07/24/2023

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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 60-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

Exit interview held and a copy of the report was provided to Hilda Cervantes, Administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Perry Scott	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC809 (FAS) - (06/04)

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