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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603608
Report Date: 12/01/2022
Date Signed: 12/01/2022 02:53:50 PM

Document Has Been Signed on 12/01/2022 02:53 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:ETHAN'S HANDS LLCFACILITY NUMBER:
198603608
ADMINISTRATOR:STEPHENSON, BERNADETTEFACILITY TYPE:
735
ADDRESS:642 PALISADE STTELEPHONE:
(626) 660-5716
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 0DATE:
12/01/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Bernadette Stephenson - Applicant TIME COMPLETED:
03:15 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an announced pre-licensing visit at the facility. LPA met with Bernadette Stephenson - Applicant.

Fire Inspection Clearance was conducted on 8/29/22 and facility is cleared to serve 4 ambulatory clients between the ages of 18 - 59 years old. The physical plant consist of; A single family home located in a residential neighborhood with a living room, dining room, kitchen, (3) client bedrooms, (1) bathroom, a front porch, a deck in the back, a back yard. Detached garage, storage shed, and an office in the back which will be inaccessible to clients.

LPA Flores conducted a tour with Bernadette Stephenson applicant and observed the following:
Living room:
Sofa cushion has design seams which is rip about 1/2 an inch in two areas. Carpet has debris and paint stains.
Dining room:
Provides a sitting area with a large dining table, dining room floors have smear stains around the dining table.
Bedrooms:
Bedroom #1(BR1) will be a shared bedroom, one night stand was observed, carpet has paint stains smear the size of 3 ft by 2 ft. Bedroom #2(BR2) will a single room and has the required furniture. Bedroom #3(BR3) will be a single room and has all required furniture, a antenna cord was observed sticking out of a hole the size of a quarter. Each bed is missing either a flat sheet,and/ or blanket.
Bathroom:
Bathroom's water temperature was tested at 119.2 degrees F., which is within the required water temperature of 105-120 degrees F. No paper towels were observed. Toilet, and shower are in working condition. During temperature test water was stopped on sink and did not properly drained.

(CONTINUED on LIC 809C)
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608
VISIT DATE: 12/01/2022
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Outdoor:
A shaded sitting area is available in the back yard. No large bodies of water were observed.
Kitchen:
Kitchen is clean and in working condition. Dishes and utensils were observed. Refrigerator/Freezer is within the required temperatures. Hand washing sign is not posted by the sink. Washer and dryer are located across from the refrigerator. Facility has (0) zero clients, food was observed for at least 2 days worth of perishables and 7 days of non-perishables.
Infection Control:
No Screening station to provide visitor's log, and symptoms was observed. Signs need to be posted throughout the facility and in main entrance.
Fire extinguisher was observed by the exit door in the kitchen. Smoke/Carbon Monoxide detectors were observed and tested. Hygiene products were observed in office, PPE supplies were observed, no face shields available. First Aid kit was reviewed no tweezers, thermometer, or first aid manual were observed.

Component III was reviewed with Bernadette Stephenson applicant.

Applicant is to correct the following within 7 days and submit pictures to the department:
  • Applicant will repair sofa cushion has design seams which is rip about 1/2 an inch in two areas.
  • Applicant will clean carpet of debris and paint stains.
  • Applicant will clean dining room floors of smear stains around the dining table.
  • Applicant will provide in BR1 an additional night stand and clean carpet's paint stains smear the size of 3 ft by 2 ft.
  • Applicant will repair hole the size of a quarter of antenna cord.
  • Applicant will provide a flat sheet, and/ or blanket in each bed.
  • Applicant will repair bathroom's sink for proper drainage.
  • Applicant will post COVID 19 signs throughout the facility with infection control prevention, will set up a screening station with visitor's log that meets Pasadena department of Public Health guidelines, provide hand sanitizer and face shields.
  • Applicant will include tweezers, thermometer, and first aid manual for first aid kit.

Exit interview was conducted with Bernadette Stephenson and a copy of this report was provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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