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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202840
Report Date: 07/26/2023
Date Signed: 07/26/2023 02:29:09 PM

Document Has Been Signed on 07/26/2023 02:29 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BENISON HOMESFACILITY NUMBER:
198202840
ADMINISTRATOR:GUTIERREZ, KHARLA SUICOFACILITY TYPE:
735
ADDRESS:22620 VAN DEENE AVENUETELEPHONE:
(310) 212-6667
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 4CENSUS: 3DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Kharla S. GutierrezTIME COMPLETED:
02:30 PM
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On 07/26/23, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with the administrator Kharla Guiterrez. LPA explained the purpose of today’s visit. The facility is licensed to operate for four (4) ambulatory adults ages 18 through 59. Todays census is 3.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: two (2) client's rooms, (1) staff room, (1) one office, (2) bathrooms, living area, dining area, kitchen, and outside patio area.

LPA walked through two (2) rooms. Bedroom 3 was designated for staff use. All bedrooms contained beds, dressers, nightstands, chairs, ample lighting and closet space. Room 4 is the designated office/storage room. Bathrooms were found to be within Title 22 regulations and were clean and operational.


LPA walked through the kitchen and all appliances were in good working order. Knives were locked and stored in a drawer in the kitchen and inaccessible to residents. LPA observed a 3-day supply of perishable and a 7-day supply of nonperishable foods. The water temperature measured 111.7 degrees Fahrenheit.


LPA toured the physical plant. There were no bodies of water or obstructions on the premises.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Records Administration (MAR) was observed to be maintained in order and accurate.

con'd on 809-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENISON HOMES
FACILITY NUMBER: 198202840
VISIT DATE: 07/26/2023
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LPA observed the facility has a 90-day supply of Personal Protective Equipment (PPE). A review of staff and resident vaccination records.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Kharla Gutierrez.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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