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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603608
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:13:28 PM

Document Has Been Signed on 01/13/2023 02:13 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
GREATER LA AC/SC, 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:
01/13/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Bernadette Stephenson - Applicant TIME COMPLETED:
02:30 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an announced subsequent pre-licensing visit to follow up on corrections needed. LPA Flores met with Bernadette Stephenson applicant.

On 12/1/22 LPA Flores conducted an announced pre-licensing visit at the location during the visit the following corrections needed to be made:
  • 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 bedroom #1(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.


During today's visit LPA conducted a tour with applicant Bernadette Stephenson and observed the following:
  • Applicant repaired sofa cushion and is in good repair.
  • Applicant change carpet throughout, in living room and in the 3 bedrooms.
  • Dining room floors look clean and in good repair.
  • Applicant provided a night stand for each client in shared bedroom #1.
  • Applicant repair hole and antenna cable sticking out in bedroom #3(BR3). Hole has been covered.
(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608
VISIT DATE: 01/13/2023
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  • Applicant provided all required bedding; mattress cover, bottom and top sheet, blanket, comforter, pillow, and pillow case were observed in each available bed.
  • Applicant repair bathroom's sink and water flows properly.
  • All infection control procedures have been set in place, a screening area with logging notebooks, thermometer, hand sanitizer, and PPE supplies, additional PPE supplies available, signs were observed throughout the facility.
  • First Aid kit was reviewed and a first aid manual, tweezers, and thermometer were observed.

Facility meets Title 22 Regulations at this time.

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

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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