198200233-9-6-2024-11-AS-TWAN-D8UVUX-20240906164529

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198200233
Report Date: 09/06/2024
Date Signed: 09/06/2024 04:45:36 PM

Document Has Been Signed on 09/06/2024 04:45 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:	CHARNOCK EAST		FACILITY NUMBER:	198200233
ADMINISTRATOR:	JOY MEMBREBE		FACILITY TYPE:	740
ADDRESS:	11365 CHARNOCK RD		TELEPHONE:	(310) 391-2423
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Minnie Joy Membrebe/ Administrator		TIME COMPLETED:	04:50 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Troy Watson conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct a one-year inspection. LPA met with the, Administrator Minnie Joy Membrebe and the purpose of the visit was discussed. Facility is licensed to serve 6 ambulatory and non- ambulatory residents and an approved hospice waiver for 2 residents. Two of the residents are diagnosed with dementia and one client is receiving hospice care services. The facility does not handle any of the residents’ money.This home is a single-story home consisting of: (5) resident bedrooms, (4) Full bathrooms, (1) guest restroom, living room, television room, dining room and kitchen, laundry room (located in the hallway) and an outdoor shaded patio area.

LPA Troy Watson toured the Resident bedrooms with the administrator Minnie Joy Membrebe, and every room had the required furniture, bed linens, lamp, chair, 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 between 105. F and 108,3 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Toxins and sharps were securely locked away and inaccessible to the clients. The stove was fully functional, and all postings were visible throughout the premises.

REPORT CONTINUES ON LIC809-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
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)

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CHARNOCK EAST	FACILITY NUMBER: 198200233
	VISIT DATE: 09/06/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 and contained the correct manual, tweezers, scissors, gauze, and tape. 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.

An Exit interview was conducted with the administrator and a copy of this report was left at the premises.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (424) 544-1088
LICENSING EVALUATOR NAME: Troy Watson	TELEPHONE: (424) 544-1069
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

LIC809 (FAS) - (06/04)

Page: 2 of 2