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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502541
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:19:23 PM

Document Has Been Signed on 10/20/2022 02:19 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
GREATER LA AC/SC, 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:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Otis Bennett/S-1TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an unannounced annual inspection focusing on the Infection Control Domain. LPA met with Mr. Bennett and discussed the purpose of today's visit.

This single-story home consists of (5) bedrooms, 2 1/2 bathrooms, a living room, den, kitchen, dinning room, laundry room and backyard. The backyard has an empty pool which is gated. LPA discussed the Infection Control Plan (LIC 9282) with Mr. Bennett and provided a copy of the LIC 9282 template.

The following was observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed throughout the facility.
  • Signs are posted to promote hand washing, cough/sneeze etiquette, and physical distancing were observed.
  • PPE supplies observed. Additional PPE supplies were stored in the hallway closets and the storage room in the backyard.
  • Hygiene and incontinence supplies observed.
  • Restrooms have hand soap, hand sanitizer and paper towels. Hand washing signs were observed posted.
  • Hand sanitizers were observed throughout the facility.
  • Sufficient supply of perishable for 2 days and non-perishable foods for 7 days were observed.
  • Medication reviewed for (1) Client (Client #1/C-1)
  • Per S-1, C-1 is fully vaccinated including the 1st booster vaccine.
  • Per S-1, staff are fully vaccinated including the 1st booster vaccine.
  • Per S-1, C-1 has flu vaccine pending.
  • Staff responsible for direct care and supervision were wearing masks.
Exit interview conducted, a copy of this report and Appeal Rights were provided to Otis Bennett/S-1. LPA was experiencing technical difficulties during this visit.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Elizabeth Irra
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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