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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502541
Report Date: 10/22/2021
Date Signed: 10/22/2021 11:42:26 AM

Document Has Been Signed on 10/22/2021 11:42 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENNETT FAMILY HOMEFACILITY NUMBER:
191502541
ADMINISTRATOR:BENNETT, OTIS LEEFACILITY TYPE:
735
ADDRESS:1477 HACIENDA PLACETELEPHONE:
(909) 629-4777
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 6CENSUS: 1DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Otis Lee Bennett, administratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Spencer conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA Spencer was greeted by administrator Otis Lee Bennett and discussed the purpose of today's visit. This single-story home contains two (2) client bedrooms, one (1) client bathroom, three (3) family bedrooms, (1.5) family bathrooms, a living room, den, kitchen, laundry room, and backyard.
The following was observed/inspected:
  • The facility had a universal entrance screening area including a thermometer, sign-in log, and PPE.
  • COVID-19 signage was placed in several areas of the facility and client temperature logs were maintained, however, staff temperature logs were not maintained.
  • Facility maintained a 30-day supply of PPE.
  • There was a sufficient supply of 2-day perishables and 7-day supply of non-perishable foods.
  • Cleaning solutions including bleach, laundry detergent, and Microban 24 were not locked and inaccessible. The administrator immediately made them inaccessible.
  • All areas were clean and in good repair.
  • Each room contained required furniture including bed, dresser, night stand, lamp and chair.
  • All client beds had required linen: mattress cover, fitted sheet, flat sheet, blanket, and comforter.
  • Bathrooms contained supplies including liquid soap, toilet paper, and paper towels.
  • Medications were locked and centrally stored. However, two (2) over-the-counter medications, Aspirin 81 mg and Vitamin B12, were observed and did not contain physician's orders and labels.
  • Staff wore face masks consistently throughout the shift and group activities were spaced to encourage physical distancing.
  • Smoke detectors/carbon monoxide detectors were present and operable.
  • A fire extinguisher was observed to be fully charged and last serviced December 2020.
  • Client files were inspected and emergency contact information and physician's reports were up-to-date.
  • All staff files were inspected and contained required health screenings, criminal record clearances, and training certificates. Administrator certificate was up-to-date expires March 2023.
Pursuant to Title 22, deficiencies were cited on attached 809D. An exit interview was conducted and a copy of this report and Appeal Rights were provided to the administrator.
SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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Document Has Been Signed on 10/22/2021 11:42 AM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/22/2021 at 11:24 AM
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: BENNETT FAMILY HOME
FACILITY NUMBER: 191502541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 due to bleach, laundry detergent, and Microban 24 being accessible posing an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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The administrator immediately placed the items in a locked area. This deficiency was corrected prior to the end of the visit.
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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/22/2021 11:42 AM - It Cannot Be Edited


Created By: LaJean Nicole Spencer On 10/22/2021 at 11:24 AM
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: BENNETT FAMILY HOME
FACILITY NUMBER: 191502541

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)
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: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above due to two over-the-counter medication Aspirin 81 mg and Vitamin B12, were observed and did not contain physician's orders and labels. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2021
Plan of Correction
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The administrator immediately removed the medications pending physician's orders. The administrator stated that he will send CCL a copy of the physician's orders and label on medications by 10/29/21.

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:Christine Yee
LICENSING EVALUATOR NAME:LaJean Nicole Spencer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2021


LIC809 (FAS) - (06/04)
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