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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603608
Report Date: 01/28/2025
Date Signed: 01/28/2025 01:34:08 PM

Document Has Been Signed on 01/28/2025 01:34 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/
DIRECTOR:		STEPHENSON, BERNADETTEFACILITY TYPE:
735
ADDRESS:642 PALISADE STTELEPHONE:
(626) 660-5716
CITY:PASADENASTATE: CAZIP CODE:
91103
CAPACITY: 4CENSUS: 3DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Alisa Merchant - Back-up Administrator
Herschelle Beasley - Care Staff		TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA was met by Herschelle Beasley Care staff and explained the purpose of the visit. Shortly after, Alisa Merchant, back-up Administrator arrived and assisted LPA with the inspection. The facility is licensed to care for (4) Developmentally Disabled Adults, non-ambulatory, ages 18 through 59. Services provided by 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. : Staff are adhering to infection control requirements. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan


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, an additional dwelling unit in the back and a detached garage. Currently, there are (3) 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. Bathroom has non-skid materials and contained hygiene supplies including liquid soap 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 and an outhouse toilet. LPA also observed a detached additional dwelling unit in the back which is being occupied by (1) staff. LPA observed trash bags, old/unused items in the back yard and open/unsecured case opening accessing the attic and the crawl space. Detached garage was also inspected. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. LPA observed a bottle of dietary supplement mixed with food seasonings in the kitchen cabinet. 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 9:50am, hot water supply measured 118 deg F 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. LPA observed that the only fire extinguisher in the facility mounted on the kitchen wall was not fully charged and was missing service tag and/or purchase receipt. Facility does not have a valid Surety Bond insurance. The patio cover in the backyard is broken and torn down. The facility has not conducted a fire drill since July 12,2024 and earthquake drill since April 20, 2024.
*****REPORT CONTINUED ON LIC809-C****
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 9
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: 01/28/2025
NARRATIVE
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Staffing: A total of eight (7) staff members including the Administrator 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 four (4) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current for some staff. However, Staff #3 does not have a current/valid first aid/CPR certificate on file. Administrator certificate is valid and expiring on 01/26/2025. Administrator has a valid HIV/AIDS training proof at the time of visit. Back-up Administrator will send CCL/LPA her current Administrator certificate. Administrator did not inform CCLD of the designated Administrator during her absence between 1/27/2025-1/29/2025.
Client Rights-Information: Client personal rights are posted. Facility has internet service accessible to all clients. Working facility phone is available and accessible to clients.
Client Records-Incident Reports: LPA did not conduct client interviews as they are all out in the community. LPA reviewed (3) client files. Client files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Client Personal Property and Clients Personal Rights observed.
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.
Health Related Services: The medications will be centrally stored and locked in the kitchen cabinet. LPA reviewed medication for (3) clients. Medications are administered as prescribed by the Physician. However, LPA observed that 2 medications for Client #2 were administered but not properly documented on Medication Administration Record (MAR) for 01/28/2025. First aid kit was inspected and observed to be fully stocked with manual.
Incidental Medical Services: There are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable.

Deficiencies cited and Technical Assistance issued. Exit interview conducted and a copy of this report was provided to Alisa Merchant, Back-up Administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 01/28/2025 01:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/28/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, the licensee did not comply with the section cited above in hat LPA observed a bottle of dietary supplement mixed with food seasonings in the kitchen cabinet which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/29/2025
Plan of Correction
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Direct care staff removed the bottle of dietary supplement and stored it in the locked medication cabinet.
***Deiciency cleared during the visit.***
Type A
Section Cited
CCR
80077.3(a)(3)(C)
Care for Clients who Lack Hazard Awareness or Impluse Control
(C) Following the disaster and mass casualty plan specified in Section 80023, fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all facility staff who provide or supervise client care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in which the facility has not conducted a fire drill since July 12,2024 and earthquake drill since April 20, 2024 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/29/2025
Plan of Correction
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Back-up Administrator agreed to conduct a fire/earthquake drill with staff and send the in-service training log to CCL/LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/28/2025 01:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/28/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in that LPA observed that the only fire extinguisher in the facility mounted on the kitchen wall was not fully charged and was missing service tags and/or purchase receipt which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/29/2025
Plan of Correction
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Back-up Administrator agreed to purchase a new fire extinguisher and keep a copy of the receipt to show purchase date for future inspections. Additionally, photo of the new fire extinguisher along with the receipt will be sent to CCL/LPA by POC due date.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, record review, the licensee did not comply with the section cited above in that Staff #3 does not have a current/valid first aid/CPR certificate on file which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/29/2025
Plan of Correction
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Administrator will ensure that all staff have current first aid/CPR certificates as required, and will send proof that Staff #3 has a scheduled First aid/CPR training by POC due date. Additionally, send a copy of the certificate to CCL/LPA once completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/28/2025 01:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/28/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(C)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (C) The date and time the PRN medication was taken, the dosage taken, and the client's response, shall be documented and maintained in the client's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that (2) medications(Loratadine 10 mg tab and Fluticasone pro 50 mcg spray) for Client #2 were administered but not properly documented on Medication Administration Record (MAR) for 01/28/2025 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 01/29/2025
Plan of Correction
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Back-up Administrator/Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all clients. Back-up Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors to CCL/LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 01/28/2025 01:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/28/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window coverings in client care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed that the window sills in the dining and client care areas were not dusted and cleaned which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator shall ensure that facility is clean at all times and will send photo of the cleaned window sills in the dining and clients areas to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed trash bags, old/unused items in the back yard and open/unsecured case opening accessing the attic and the crawl space which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator shall ensure that the facility's surrounding is clean and will send proof that the trash bags, unused items had been removed in the backyard and openings covered. Photos will be submitted to CCL/LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 01/28/2025 01:34 PM - It Cannot Be Edited


Created By: Bennette Pena On 01/28/2025 at 12:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(b)
Bonding
(b) All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview, record review, the licensee did not comply with the section cited above in that the facility does not have a valid Surety Bond insurance which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator will submit proof that the Surety Bond insurance has been renewed to CCL/LPA by POC due date.
Type B
Section Cited
CCR
85064(f)
Administrator Qualifications and Duties
(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable, of, and responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview, record review, the licensee did not comply with the section cited above in that the Administrator did not inform CCLD of the designated Administrator during her absence between 1/27/2025-1/29/2025 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 01/31/2025
Plan of Correction
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Administrator will submit a completed Designation of facility responsibility to CCL/LPA by POC due date. Additionally, Administrator will send a signed statement stating that she has read, reviewed and understood CCR85064 regulation to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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