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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602122
Report Date: 05/01/2023
Date Signed: 05/01/2023 12:14:22 PM

Document Has Been Signed on 05/01/2023 12:14 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, 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: DATE:
05/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Maxine WashingtonTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced Required - 1 Year visit, with a primary focus on infection control measures. Upon arrival at the facility, LPA met with Staff, Maxine Washington, Direct Support Professional and conducted a risk assessment. LPA Shirley spoke with and explained to Licensee 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. The facility annual fees are due and mentioned to Licensee, 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 aged 18-59 ambulatory. LPA Shirley and Maxine 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 106.4 degrees Fahrenheit.

Continued LIC 809-C page #2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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: 05/01/2023
NARRATIVE
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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. There is an ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted monthly. 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. The facility has a 60-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA also noted that the records for staff and residents were not available as this is a regulation and deficiency/ies must be cited.

Deficiencies are cited from Title 22 and the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

An Exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeals rights were discussed and left for the Licensee Beverly Creel and reviewed by Maxine Washington whose signatures on this form confirm receipt of these documents.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2023 12:14 PM - It Cannot Be Edited


Created By: Felisa Shirley On 05/01/2023 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENEVOLENT RESIDENTIAL CARE FACILITY INC
FACILITY NUMBER: 198602122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in which 2 out of 2 persons, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2023
Plan of Correction
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Licensee stated that she will leave a set of keys at the facility from now on.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/01/2023 12:14 PM - It Cannot Be Edited


Created By: Felisa Shirley On 05/01/2023 at 11:46 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENEVOLENT RESIDENTIAL CARE FACILITY INC
FACILITY NUMBER: 198602122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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Licensee stated that she will leave set of keys at the facility from now on.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Felisa Shirley
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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