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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603608
Report Date: 01/27/2024
Date Signed: 01/27/2024 12:50:58 PM

Document Has Been Signed on 01/27/2024 12:50 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
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:
01/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Bernadette Stephenson - Licensee/AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Ben Robertson/Staff, Jean Roberston/Staff and Bernadette Stephenson, Licensee/Administrator and explained the purpose of the visit. The facility is licensed to care for (4) Developmentally Disabled Adults, non-ambulatory, ages 18 through 59. There's zero (0) clients in the facility during the visit. Licensee/Administrator stated that she is in the process of applying vendorization from Frank D. Lanterman Regional Center.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. None of the staff were wearing masks and staff are aware to use disposable gloves to clean and disinfect the high touched surfaces in the common areas. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. COVID-19 signs are posted in the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.
Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of (3) client bedrooms, (1) bathroom, a living room, kitchen, dining area, backyard, and a detached garage. Currently, there are no clients living in the facility. The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and LPA observed a locked small shed used as a storage. LPA also observed a small dwelling unit in the back which is being occupied by (2) staff only. LPA also observed miscellaneous items in the side yard which was cleaned up during the visit. Detached garage was also inspected. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. There is a fire extinguisher mounted on the kitchen wall observed to be fully charged. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. At 10:25am, hot water supply measured 116.3 in bathroom #1.
Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been submitted to CCL. A fire clearance for (4) clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and $3,000,000.00 in the total annual aggregate is valid and will expire on 11/28/2024. Surety Bond (Western Surety Company) is valid with bond amount of $6000. Last Fire and Earthquake Drills were conducted on 11/15/2023 and drills with staff are to be conducted on a quarterly basis.
*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024
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
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: 01/27/2024
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Staffing: A total of eight (8) staff members including the Administrator will provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.
Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and expiring on 01/26/2025. Administrator has a valid HIV/AIDS training proof at the time of visit.
Client Rights-Information: Client personal rights are posted. Per Administrator, facility has internet service accessible to all clients. Working facility phone is available and accessible to clients. LPA did not conduct client interviews as there are no clients admitted to the facility yet.
Client Records-Incident Reports: LPA did not review any Client files during the visit.
Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.
Health Related Services: The medications will be centrally stored and locked in the kitchen cabinet. No medications reviewed during the visit. First aid kit was inspected and observed to be fully stocked with manual. The facility plans to use TheraP electronic record to document medications given to future clients.
Incidental Medical Services: Per the Administrator, she does not plan to admit clients who have prohibited health conditions.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Exit interview conducted, Technical assistance issued and a copy of this report was provided to Bernadette Stephenson, Licensee/Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2024
LIC809 (FAS) - (06/04)
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