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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320406
Report Date: 11/21/2024
Date Signed: 11/22/2024 10:03:40 AM

Document Has Been Signed on 11/22/2024 10:03 AM - 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BLESSED HANDS RESIDENTIAL CARE FACILITY FOR THEFACILITY NUMBER:
198320406
ADMINISTRATOR/
DIRECTOR:		TYSON, JANETFACILITY TYPE:
740
ADDRESS:17513 VALMEYER AVENUETELEPHONE:
(323) 218-1451
CITY:GARDENASTATE: CAZIP CODE:
90248
CAPACITY: 6CENSUS: 0DATE:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Janet Tyson, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 11/21/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced required annual visit using the full CAREs Inspection Tool. LPA met with Administrator, Janet Tyson and explained the purpose of today’s visit. The facility is licensed to serve elderly developmentally disabled residents ages 60 and over. This facility has a approved fire clearance for six (6) ambulatory only residents. Approved hospice waiver for two(2) hospice residents. There are no residents in placement at this time.

LPA reviewed the Administrator's personnel file and found that it contained all required documents. During file review, LPA observed the liability insurance.

LPA Felisa and Janet toured both inside and outside of the facility. The facility is a one-story structure located in a residential neighborhood. The facility consists of (3) client bedrooms, (1) staff bedroom, (2) bathrooms, living room, kitchen, dining area, and patio. Facility maintains all required posting throughout the facility.

All bedrooms were toured. Bedrooms 1-3 will be occupied by residents and contain the mandated furniture. LPA observed all rooms to have the required furniture including a bed, nightstand, and chair(s). All beds had the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillow. LPA observed ample lighting in all the bedrooms.

LPA Shirley and Janet toured the kitchen and found it to be clean and sanitary. All appliances were in good working order. Knives were locked and stored. The medication cabinet was locked and located in the kitchen. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods.

The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual. The Administrator owns a gun and the bullets are stored separately from the gun. There are no bodies of water present. This facility is in good repair.

Con'd 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BLESSED HANDS RESIDENTIAL CARE FACILITY FOR THE
FACILITY NUMBER: 198320406
VISIT DATE: 11/21/2024
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LPA Shirley and Janet walked through all common areas. In the living room, kitchen, dining room there is ample seating and space for all residents. All rooms and walkways were clean, and clear of obstructions and hazards. All areas have ample lighting. All rooms, hallway, and living room have working smoke detectors. There is a charged fire extinguisher in the kitchen. The backyard is clean and clear of obstructions and hazards, and there are no bodies of water present.

There are no deficiencies observed.


An exit interview was conducted, and a copy of this report was provided to Administrator, Janet Tyson.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
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