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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502541
Report Date: 10/04/2024
Date Signed: 10/07/2024 08:14:09 AM

Document Has Been Signed on 10/07/2024 08:14 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENNETT FAMILY HOMEFACILITY NUMBER:
191502541
ADMINISTRATOR/
DIRECTOR:		BENNETT, OTIS LEEFACILITY TYPE:
735
ADDRESS:1477 HACIENDA PLACETELEPHONE:
(909) 629-4777
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 6CENSUS: 1DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Otis Bennett, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analysts (LPAs) Cynthia Chan and Mayra Cota conducted the unannounced annual inspection. LPA met with licensee Otis Bennett and explained the purpose of the visit. The facility is licensed to 6 serve mentally disabled adults, ages 18 to 59, and ambulatory only. There is currently one client residing at the home.

The facility consists of 5 bedrooms, 2 1/2 bathrooms, living room, dining room, den, kitchen, laundry room and a garage. The backyard has an empty pool which is gated. There is a fireplace that is not in use and covered. Knives and cleaning solutions are locked and inaccessible to client. Licensee has the Infection Control Plan and continuing to follow the current guidance. Gloves are worn when deemed necessary. Food supplies of perishable and non-perishable are sufficient. There is a carbon monoxide detector in the hallway and is operable. The hot water temperature is measured within the required range of 105 - 120 degrees F.
Licensee/Administrator (Otis Bennett) certificate expires on 3/11/24 but was verified the documents were submitted for renewal. Administrator has current First Aid/CPR training. Other individuals residing in the home are fingerprinted cleared. Administrator's file has the required documents, including Health Screening and Tuberculosis results. LPAs reviewed 1 client file and it contained the required documents. Facility does not handle P&I money for client. Medication for client is being administered as prescribed. Administrator provides care and supervision to client at all times. There is no manual restraints used at this home. Client is provided with internet access and device to use. Facility has the updated Emergency Disaster Plan and is conducting monthly drills.

No deficiencies issued today. An exit interview was held and a copy of this report was given to Mr. Bennett.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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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