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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191601495
Report Date: 09/30/2021
Date Signed: 09/30/2021 02:55:28 PM

Document Has Been Signed on 09/30/2021 02:55 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:W.L.A. HOMESFACILITY NUMBER:
191601495
ADMINISTRATOR:SAM MAGHAZEIFACILITY TYPE:
740
ADDRESS:11373 CHARNOCK RD.TELEPHONE:
(310) 915-9196
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY: 6CENSUS: 3DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joy Membrebe, Administrator TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced annual visit to W.L.A. Homes. The purpose of this visit was to conduct an annual inspection. LPA met with Administrator Joy Membrebe and explained the reason for the visit. Facility is licensed to serve clients age 60 and over and retain 6 non-ambulatory residents. The facility currently has 3 residents in care. The facility does not handle any of the residents’ money.

During the visit, LPA Jones toured the physical plant, checked food service, inspected the facility inside and outside. The home consists of 4 resident bedrooms, 2 staff bedroom, 2 resident bathrooms, 2 staff bathroom, an office garage, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens 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. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All exit doors and windows have auditory alarms that are operable.

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. 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. Each resident has their own room for isolation. LPA observed required postings throughout the facility. LPA observed PPE supplies on the patio. The administrator advised LPA that visitors have the
SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
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: W.L.A. HOMES
FACILITY NUMBER: 191601495
VISIT DATE: 09/30/2021
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option to meet with the residents inside or outside by appointment only.

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

SUPERVISORS NAME: Michael Cava
LICENSING EVALUATOR NAME: Jennifer Jones
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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