198602122-5-31-2024-11-AS-PBUR-D5T7PG-20240531215019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602122
Report Date: 05/30/2024
Date Signed: 05/31/2024 09:50:55 PM

Document Has Been Signed on 05/31/2024 09:50 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BENEVOLENT RESIDENTIAL CARE FACILITY INC		FACILITY NUMBER:	198602122
ADMINISTRATOR/ DIRECTOR:	BEVERLY CREEL		FACILITY TYPE:	735
ADDRESS:	9819 SOUTH 10TH AVENUE		TELEPHONE:	(310) 673-7750
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90305
CAPACITY: 4		CENSUS: 2	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Beverly Creel		TIME VISIT/ INSPECTION COMPLETED:	01:30 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) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Licensee/Administrator Beverly Creel and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report and infection control plan. There are currently two (2), Westside Regional Center (WRC) Adult Residential Care Facility (ARF) consumers in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Physical Plant & Environmental Safety, Operational Requirements, Staffing, Personnel Records-Training, Client Rights-Information, Client Records-Incident Reports, Food Service, Health-Related Services, Incidental Medical Services, Disaster Preparedness, and Emergency Intervention. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-family home located in a residential neighborhood. Administrator Beverly Creel and LPA Bunker toured the facility which consisted of the following: Living room, dining room, kitchen, breakfast area, staff room/den, 2 bedrooms, 1.5 bathrooms, laundry room, shaded patio area, attached garage, and indoor/outdoor activity areas. The front and back yard landscape is in good condition at the time of the visit. During the tour, LPA observed the facility’s infection control practices. See continued LIC809-C on page 2

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENEVOLENT RESIDENTIAL CARE FACILITY INC	FACILITY NUMBER: 198602122
	VISIT DATE: 05/30/2024

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

Continued LIC809-C page 2

During the tour, LPA Bunker observed a sanitizing station; hand sanitizer, visitor sign-in log, and thermometer at the facility's front entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing. Administrator Beveryl Creel indicates that the Administrator reviews the PINS and is up to date on the PINs.

Documents are posted as mandated on the walls and the dining room. Bedrooms contain the furniture mandated, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are in a locked cabinet in the kitchen, and records are current. Common areas were observed for the ability to safely serve the needs of the clients, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured at 110 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguisher is fully charged, adequate linen supply, the facility telephones are working. The client's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. The facility conducted a fire drill on March 13, 2024.

There were no deficiencies cited.
Exit interview conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2