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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320563
Report Date: 08/20/2025
Date Signed: 08/20/2025 10:51:21 AM

Document Has Been Signed on 08/20/2025 10:51 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:IN R GREAT HANDS - STEVELYFACILITY NUMBER:
198320563
ADMINISTRATOR/
DIRECTOR:		IN, RIZAFACILITY TYPE:
740
ADDRESS:3439 STEVELY AVE.TELEPHONE:
(562) 276-8506
CITY:LONG BEACHSTATE: CAZIP CODE:
90808
CAPACITY: 6CENSUS: 0DATE:
08/20/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Riza In, Administrator/ LicenseeTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 08/20/2025 at 9:20am, Licensing Program Analyst (LPA) Zina Brown conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA Zina Brown met with applicant Riza In, Administrator/ Licensee.

An application was submitted to CCLD on 01/03/2025, for an Residential Care Facility for the Elderly (RCFE) to serve elderly residents and dementia adults for ages 60 and over. The requested capacity is for six (6) residents of which five (5) are non-ambulatory and one (1) is bedridden.

Structure:
The facility is a (5) bedroom, (2) bathroom, single story house with a  attached garage. The facility is a  structure with 5 bedrooms, 2 bathrooms, 1 living room with a TV, a kitchen, and a backyard accessible to residence. There is backyard has an outside shaded patio area. The resident five (5) bedrooms are spacious and will easily accommodate the residence furnishings.

Bedroom Structure
All five (5) bedrooms have the following one (1) bed, one (1) lamp, one(1) dresser and or closet, and one (1) one (1) chair. In bedroom #5 the exit door has a signal auditory alarm.

Bathroom Structure
All two (2) bathrooms have a working toilet, wash basin, shower with a rail and a slip grip ma. All (2) bathrooms can accommodate non-ambulatory clients in a wheel chair. Water temperature for each bathroom are as followed bathroom #1 at 110.8 °F and bathroom #2 at 112.6°F

Report continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 5
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: IN R GREAT HANDS - STEVELY
FACILITY NUMBER: 198320563
VISIT DATE: 08/20/2025
NARRATIVE
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Component III:
During the conducted pre-licensing visit, between the hours of 9:21am - 9:28am an orientation of the component III information was provided to the licensee about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Zina Brown 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 assigned to their application.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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: IN R GREAT HANDS - STEVELY
FACILITY NUMBER: 198320563
VISIT DATE: 08/20/2025
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Toxins:
All toxins are locked and stored in.   

Water Temperature:
The water in each bathroom tested at 110.8 °F (bathroom 1), 112.6 °F  (bathroom #2) and 110.5 °F (in kitchen)

Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in hallway area, available for staff use but inaccessible to residence.

Residents & Staff Files:
At the time of pre-licensing, no resident and staff files were reviewed as the facility is awaiting approval for licensing.

Reading Material, Games, Equipment &  Materials:
The facility hasbooks, and other recreational materials for the resident 's use and commensurate with the plan of operation.
                        
Pool/Jacuzzi & Pets:
No located at the time of inspection.

Fire clearance:
Fire clearance for six (6) residents of which five (5) residents can be non-ambulatory and one (1) resident can bedridden at the residential care facility for the elderly was approved on 01/28/2025. In one of the five bedrooms there is a exit door with a auditory alarm in bedroom # 5 which is the assigned bedridden room.  

Pre-licensing Checklist: Completed by licensee and reviewed by LPA.

Report continues on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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: IN R GREAT HANDS - STEVELY
FACILITY NUMBER: 198320563
VISIT DATE: 08/20/2025
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Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in main entry area of the home.

Emergency Phone Numbers, Exit Plan & Menu:
The facility has a working phone line and internet. Upon entering the facility there, is a posted board that is readily available with a evacuation plan, fire prevention, emergency plan, infection control plan and personal righst. Fire Extinguisher is located near kitchen mounted on wall which is fully charged.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked cabinet near the refrigerator. Food supply adequate stored in cabinet and consists can goods. The water temperature in the kitchen is at 110.5 °F. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
In the facility there are nine (9) smoke detectors with carbon monoxide detectors that are electrical & connected. Battery operated & working.

Appliances:
In the facility is a working stove burners, oven, microwave, washer, and dryer. There is one (1) refrigerator in the kitchen that is measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at 0 zero degrees Fahrenheit. The residence is equipped with central air and heat and each resident bedroom is individually climate controlled.
  
Report continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Zina Brown
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
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