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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603608
Report Date: 11/25/2025
Date Signed: 11/25/2025 04:41:47 PM

Document Has Been Signed on 11/25/2025 04:41 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
MONTEREY PARK ASC, 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:
11/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Ben Robertson, House ManagerTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit. LPA arrived to the facility at 2:00pm and no one was home. LPA contacted the Administrator, Bernadette Stephenson, who stated that the House Manager will arrive shortly. At 2:20pm, House Manager, Ben Robertson arrived. LPA was met by House Manager, Ben Robertson and assisted LPA with the inspection. LPA explained the purpose of the visit. Shortly after, Bernedette Stephenson, House Manager 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 Proective Equipment (PPEs) were maintained. Staff are adhering to infection control requirements. The facility has an Infection Control Plan in place.

Physical Plant/Environment Safety: The facility is a single-story 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. The interior and exterior physical plant was inspected. Backyard has shaded area. 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. 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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608
VISIT DATE: 11/25/2025
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Physical Plant/Environment Safety [Cont.]: Smoke alarms and carbon monoxide were tested and operable. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 112.2 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 Fire Extinguisher is fully charged. LPA observed facility has a valid Surety Bond insurance and valid liability insurance in place. Last Fire Drill was conducted on 11/02/2025. Last Earthquake Drill was conducted on 11/02/2025.

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 are associated to the facility.

Personnel Records/Staff Training: LPA reviewed files for four (4) staff which includes personnel record, health screening, TB clearance, Employee Rights, 1st Aid/CPR training, DSP 1 and 2 training, and staff training. Administrator certificate is valid and expires on 01/26/2027. Administrator’s file has valid HIV/AIDS training.

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 reviewed three (3) client files which include Face sheet,. Identification and Emergency Information, Admission Agreement, Physician's Report (including TB and Ambulatory Status), IPP (Individual Program Plan, Pre-Placement Appraisal, Functional Capability Assessment, and Clients Personal Rights.

Food Service: LPA observed the Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. 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. First aid kit was inspected and had all required items.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: ETHAN'S HANDS LLC
FACILITY NUMBER: 198603608
VISIT DATE: 11/25/2025
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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 plan.

Emergency Intervention: The facility does not use any restraints or seclusion.

Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies observed during the visit. Exit interview and a copy of this report was provided to the as provided to the Administrator, Bernadette Stephenson.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2025
LIC809 (FAS) - (06/04)
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