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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200233
Report Date: 09/21/2023
Date Signed: 09/21/2023 03:42:27 PM


Document Has Been Signed on 09/21/2023 03:42 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 ASC, 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:
09/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Siamak MaghazeiTIME COMPLETED:
04:00 PM
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On 9/21/2023, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Licensee, Sam Maghazei and Administrator, Joy Membrebe. LPA explained the purpose of the visit and were accompanied by Licensee and Administrator inside and outside the facility during this inspection.

The home consists of 5 client 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.

Facility is licensed to serve six (6) residents, three (3) may be non-ambulatory. The facility also has an approved hospice waiver for two (2) residents. The facility currently has 2 non-ambulatory residents. 1 resident is receiving Hospice services.

During the visit, LPA observed the facility infection control practices. LPA observed a screening station with a sign in sheet for visitors and thermometer with available PPE supplies. LPA was screened upon entering the facility.

3 staff records were reviewed, 3 out of 3 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHARNOCK EAST
FACILITY NUMBER: 198200233
VISIT DATE: 09/21/2023
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3 resident records were reviewed and, 3 out of 3 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.

An exit interview was conducted, Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Administrator.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Socorro LeandroTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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