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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320406
Report Date: 10/25/2023
Date Signed: 10/25/2023 04:17:24 PM

Document Has Been Signed on 10/25/2023 04:17 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BLESSED HANDS RESIDENTIAL CARE FACILITY FOR THEFACILITY NUMBER:
198320406
ADMINISTRATOR:TYSON, JANETFACILITY TYPE:
740
ADDRESS:17513 VALMEYER AVENUETELEPHONE:
(323) 218-1451
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY: 6CENSUS: DATE:
10/25/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Janet Tyson, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA) Felisa Shirley made an announced visit and met with applicant/ administrator Janet Tyson to conduct a Pre-Licensing evaluation. The requested capacity is for six (6) ambulatory clients.

Structure: Facility is a one story family home with four bedrooms, one private bedroom and three (3) client bedrooms, two (2) full bathroom, living room, dining area/small office, kitchen, washer and dryer appliances are located in the kitchen. A locked file cabinet located in the dining room will be used to store client and staff files. First aid kit, and first aid manual will be stored on a shelf located above the washer and dryer. There are two exits, main exit is located in living room, and exit two (2) is located off of the dining room. Front yard landscape is in good condition at time of visit. Bedroom Residents: Bedrooms are equipped with one bed per client, nightstand, chair, and one lamp. LPA observed activities available for clients. Bathrooms: Two (2) bathrooms have a working toilet, wash basin, and a bathtub/ shower, LPA observed grab bars and non-slip strips. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Two (2) fully charged fire extinguishers located in the kitchen and dinning room. LPA observed sufficient hygiene supplies for clients.

Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in the locked medication cabinet. Smoke Detectors/Carbon Monoxide(s): Facility is equipped with operational dual and hardwired smoke detectors in all bedrooms and mounted on the ceiling.

LPA observed three day perishables, and seven days plus supply of non-perishable food.

Appliances: Stove burners (electric), oven, microwave, and washer/dryer are in working condition. There is one working (1) refrigerator in the home and one (1) freezer located in the garage.



Cont'd on 809-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BLESSED HANDS RESIDENTIAL CARE FACILITY FOR THE
FACILITY NUMBER: 198320406
VISIT DATE: 10/25/2023
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Component III was reviewed with applicant/ administrator Janet Tyson, who is familiar with tittle 22 regulations.

During the pre-licensing inspection zero (0) items were observed that didn’t comply with applicable laws and regulations.

LPA reminded applicant the following items shall be posted always: Emergency numbers, Personal rights, Emergency Disaster Plan, Complaint Procedures, and facility sketch show emergency exits.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst. Applicant advised to contact LPA when first clients becomes admitted to facility.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC809 (FAS) - (06/04)
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