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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191502541
Report Date: 10/31/2025
Date Signed: 10/31/2025 04:13:00 PM

Document Has Been Signed on 10/31/2025 04:13 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/
DIRECTOR:		BENNETT, OTIS LEEFACILITY TYPE:
735
ADDRESS:1477 HACIENDA PLACETELEPHONE:
(909) 629-4777
CITY:POMONASTATE: CAZIP CODE:
91768
CAPACITY: 6CENSUS: 1DATE:
10/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Otis Lee Bennett - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced required 1-year visit. LPA met with Otis Lee Bennett, Licensee/Administrator and discussed the purpose of the visit. The facility is licensed to serve (6) mentally disabled adults, ages 18 to 59, ambulatory only. Currently, there is one (1) client residing at the home. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The home consists of five (5) bedrooms, two and a half (2 1/2) bathrooms, living room with covered fireplace, den, dining room, kitchen, laundry area and attached garage. Client bedroom was toured, has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Smoke alarms and carbon monoxide were tested and operable. All toilets, hand washing, and bathing facilities are in operating condition. Supplies of nonperishable foods are maintained on the premises to last for a minimum of one week and fresh perishable foods for a minimum of two days for the amount of clients being served. LPA observed cleaning solutions and disinfectants in an unlocked cabinet under the kitchen sink. Administrator removed and stored it in a locked cabinet during the visit. No firearms nor other dangerous weapons are kept at the facility. Hot water temperature measured is within the required range of 105-120 deg F under Title 22 regulations. There is (1) fire extinguisher mounted on the kitchen wall which was last serviced on 01/16/2025. All outdoor and indoor passageways were free of obstruction. Backyard was inspected and has an empty pool which is gated. There are no cameras in the facility. Licensee has the Infection Control Plan and continuing to follow the current guidance. ***CONTINUED ON LIC809-C***

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2025
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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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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BENNETT FAMILY HOME
FACILITY NUMBER: 191502541
VISIT DATE: 10/31/2025
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Only (1) staff member, the Licensee/Administrator provides care and supervision to meet the client's needs. LPA reviewed the Administrator's file and has the required documents, including Health Screening and TB test results. Administrator has a criminal record clearance, fingerprint cleared, first aid/CPR training and associated to the facility. Administrator's certificate is valid and expires on 03/12/2026.

LPA reviewed the client's file and it contained the required documents. LPA reviewed medication for the client and is administered as prescribed. Administrator maintains his own record/log. Medication is kept in a safe and locked place that is inaccessible to the client.

Administrator does not handle cash resources for the client. The last fire drill was conducted on 10/02/2025. The facility has a complete Emergency Disaster and Mass Casualty Plan.

Deficiency cited. Exit interview conducted and a copy of this report was provided to Otis Lee Bennett, Licensee/Administrator.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2025 04:13 PM - It Cannot Be Edited


Created By: Bennette Pena On 10/31/2025 at 02:34 PM
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: 10/31/2025

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 that LPA observed cleaning solutions and disinfectants in an unlocked cabinet under the kitchen sink which are accessible to the client which poses an immediate health, safety or personal rights risk to client in care.
POC Due Date: 10/31/2025
Plan of Correction
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****DEFICIENCY CLEARED DURING THE VISIT.*****
Administrator removed and stored all the cleaning supplies, disinfectants in a locked cabinet during 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Bennette Pena
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2025


LIC809 (FAS) - (06/04)
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