<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602122
Report Date: 05/10/2023
Date Signed: 10/17/2023 10:47:46 AM

Document Has Been Signed on 10/17/2023 10:47 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: DATE:
05/10/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Maxine WashingtonTIME COMPLETED:
11:00 AM
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
On 5/10/23 LPA Felisa Shirley returned unannounced to the facility to continue Annual Required - 1yr visit. LPA met with Maxine Washington, Caregiver. The current census is 3.

LPA Felisa reviewed all staff personal files, resident files and LIC 500 and found that all staff are associated with our records in Guardian.

No deficiencies were cited.

An exit interview was conducted and a signed copy of this report was left for the Licensee and given to Maxine Washington.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2023
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 1