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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202840
Report Date: 06/13/2024
Date Signed: 06/13/2024 03:59:45 PM

Document Has Been Signed on 06/13/2024 03:59 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BENISON HOMESFACILITY NUMBER:
198202840
ADMINISTRATOR/
DIRECTOR:		GUTIERREZ, KHARLA SUICOFACILITY TYPE:
735
ADDRESS:22620 VAN DEENE AVENUETELEPHONE:
(310) 212-6667
CITY:TORRANCESTATE: CAZIP CODE:
90502
CAPACITY: 4CENSUS: 3DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:52 PM
MET WITH:Kharla GutierrezTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 06/13/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit to the facility listed above. LPA met with Administrator, Kharla Guiterrez, and the purpose of today’s visit was explained. The facility is licensed to operate for four (4) ambulatory adults ages 18 through 59. There are currently three (3) Clients residing in the facility.

Physical Plant/Structure The facility is a single-story home in a residential neighborhood. It consists of two (2) client bedrooms, one (1) staff room, an office, two (2) bathrooms, living room, activity room, dining room, kitchen, and outside patio area. The patio has a table with umbrella and chairs. LPA observed all walkways around the home to be clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises.

Bedroom LPA inspected the two (2) client bedrooms and found the walls and floors to be clean and in good repair. LPA observed the rooms have the required furniture including a bed, dresser, nightstand, storage space for client’s belongings, and ample lighting. LPA observed the beds have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of linens in Client’s closets and in a cabinet in the hallway.



Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENISON HOMES
FACILITY NUMBER: 198202840
VISIT DATE: 06/13/2024
NARRATIVE
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Bathrooms LPA inspected the facility bathrooms and found them to be within Title 22 regulations. All bathrooms were observed clean and operational. LPA observed storage area for personal hygiene products. LPA observed an ample supply of towels and personal hygiene products available for clients. All showers had a nonskid material and secured safety handrails. The water temperature measured 107.1-degrees and 107.8- degrees Fahrenheit.

Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. LPA observed all appliances to be operable and in good repair. LPA observed an ample supply of dishware, cookware, and cutleries. LPA observed a 2-day supply of perishable foods and a 7-day supply of non-perishable foods properly stored and labeled. The water temperature measured 106.8-degrees Fahrenheit. All sharps are secured in a locked drawer and are inaccessible to clients. All cleaning supplies are secured in a locked cabinet under the kitchen sink or in a locked cabinet in the laundry and are inaccessible to clients.

Common Rooms LPA observed the facility to be appropriately furnished during the time of visit. The facility has a living room with a couch to accommodate all clients. In the activity room, LPA observed couches to accommodate all clients. Additionally, in the activity room, LPA observed a table for clients to work on projects. LPA observed a cabinet with games, activities, crafts, puzzles, and books. In the activity room is a desk and computer for clients to use. The dining room has a large table and chairs to accommodate clients for meals. LPA observed all walkways and hallways to be clean, clear, and free of hazards and obstructions.



Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENISON HOMES
FACILITY NUMBER: 198202840
VISIT DATE: 06/13/2024
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All rooms were observed with ample lighting. The facility was kept at a comfortable temperature.
Medications LPA observed all Centrally Stored Medications secured in a locked closet in the hallway and are inaccessible to residents. All medications were observed in their original packaging. LPA reviewed the medications and Medication Administration Record (MAR) for the three (3) residents. Three (3) out of three (3) resident’s MARs and medication are consistent with properly documented records.
File Review/Interviews LPA reviewed the files for the three (3) clients and found they had the required documents. LPA interviewed one client and they were happy with the care they receive at the facility. LPA reviewed the file for the Administrator and two (2) staff and found they had the required training, certification, and documents. The administrator’s Administrator Certificate is valid till 10/25/25. LPA interviewed two (2) staff, and all were able to answer questions regarding policy, procedure, resident care, and personal rights. LPA reviewed the facility Surety Bond that is effective till 02/07/28.
Safety LPA observed a fire extinguisher located in the dining room, last serviced on 12/28/23. All smoke and carbon monoxide detectors are operable. The last emergency drill was conducted on 05/24/24. LPA inspected the First Aid kit and found it contained the required items and a manual. The facility sketch is posted at the entrance of the facility. The facility’s Emergency and Disaster Plan is posted at the entrance of the facility. LPA observed all required documents posted in the facility. The facility has a working landline telephone. There are no firearms are ammunition stored at the facility.
Continued on LIC809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENISON HOMES
FACILITY NUMBER: 198202840
VISIT DATE: 06/13/2024
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Infection Control LPA observed a sanitizing station and visitor sign-in log. LPA observed on the table there is hand sanitizer, gloves, and masks available. LPA observed all required Infection Control signs posted in the facility. LPA observed a 60-day supply of Personal Protective Equipment (PPE). Upon arrival, staff and client’s temperature is taken.

During today’s visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Kharla Gutierrez, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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