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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602122
Report Date: 09/08/2022
Date Signed: 09/08/2022 10:40:35 AM

Document Has Been Signed on 09/08/2022 10:40 AM - 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:BENEVOLENT RESIDENTIAL CARE FACILITY INCFACILITY NUMBER:
198602122
ADMINISTRATOR:BEVERLY CREELFACILITY TYPE:
735
ADDRESS:9819 SOUTH 10TH AVENUETELEPHONE:
(310) 673-7750
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY: 4CENSUS: 3DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Beverly CreelTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Required - 1 Year visit, with a primary focus on infection control measures. Upon arrival at the facility, LPA met with licensee, Beverly Creel and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. LPA Scott informed Beverly Creel that the purpose of today's visit was to conduct the facility Annual inspection, review the physical plant, medications, food service, clients, and staff records. LPA was properly screened for Covid-19 symptoms and temperature was checked and logged in the visitor’s book. The facility annual fees are current, and a current mitigation plan is on file.


The facility is a single-story corner home located in a residential neighborhood. It has a capacity for four (4) residents age 18-59 ambulatory. LPA Scott and Creel made a complete tour of the facility which included: Living room, dining room, kitchen, breakfast area, den, 2 bedrooms, 1.5 bathrooms, laundry room, attached garage, shaded area, indoor/outdoor activity areas. Knives and toxins were kept under lock and key.

Documents were posted as mandated. The following Title 22 regulated areas were audited and found to be complying: Bedrooms contain the required furniture. The client’s bedrooms were inspected for safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature is 106.1 degrees Fahrenheit.

Continued LIC 809-C page #2
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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: BENEVOLENT RESIDENTIAL CARE FACILITY INC
FACILITY NUMBER: 198602122
VISIT DATE: 09/08/2022
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There is a working telephone, smoke and carbon monoxide detectors were complying, fire extinguisher is fully charged and last serviced on 06/01/22. Medications were centrally stored and properly locked in the hallway cabinet and records are current. There is an ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on 06/01/22. The exterior was free from hazards and obstructions.


During the visit, LPA observed the following to be complying: the facility's infection control practices; screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms; licensee was wearing a face covering; the facility has a 90-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

There were no deficiencies cited.



An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Licensee, Beverly Creel.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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