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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200233
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:00:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CHARNOCK EASTFACILITY NUMBER:
198200233
ADMINISTRATOR:JOY MEMBREBEFACILITY TYPE:
740
ADDRESS:11365 CHARNOCK RDTELEPHONE:
(310) 391-2423
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 5DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Joy Membrebe, Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced visit to Charnock East. The purpose of today’s visit was to conduct the annual inspection. LPA met with Administrator, Joy Membrebe. Facility is licensed for 6 non-ambulatory residents. The facility also has an approved hospice waiver for 1 resident. The facility currently has 5 residents. The facility does not handle any of the residents’ money.

LPA Jones toured the physical plant, checked food service, reviewed staff records and reviewed resident files for medical status. The home consists of 5 resident bedrooms, 1 staff bedroom, 4 resident bathrooms including 1 staff bathroom, living room, dining room, laundry area and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Bathrooms were inspected during the tour. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Exit doors have auditory alarms. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All medications were securely locked and inaccessible to residents. Smoke detectors /carbon monoxide detectors were working properly, and fire extinguisher was fully charged. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

During the visit, LPA observed the facility infection control practices. LPA observed a screening station with a sign in sheet for visitors and thermometer. LPA was screened upon entering the facility. LPA observed staff wearing a mask. Two residents share a room and the additional residents in care have their own room. LPA observed a vacant room for isolation. LPA observed required postings throughout the facility. LPA observed PPE supplies in the dining area located near the kitchen. The administrator advised LPA that visitors have the option to meet with the residents inside or outside by appointment only.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHARNOCK EAST
FACILITY NUMBER: 198200233
VISIT DATE: 09/30/2021
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No immediate health and safety concerns

No Deficiencies cited

Exit interview conducted and a copy of the report was given at the time of the visit.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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