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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601970
Report Date: 10/10/2022
Date Signed: 10/10/2022 03:56:32 PM

Document Has Been Signed on 10/10/2022 03:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENOR HOMEFACILITY NUMBER:
198601970
ADMINISTRATOR:LOLITA TANFACILITY TYPE:
735
ADDRESS:13439 FLATBUSH AVENUETELEPHONE:
(562) 864-7814
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 2CENSUS: 1DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Licensee Lolita TanTIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required 1 year inspection at the facility and met with Licensee/Administrator Lolita Tan and explained the purpose for todays visit. Staff Census: 3 and Administrator Certificate Expires on 1/17/24 for Lolita Tan.

The facility consist of four bedrooms: two for clients / one for staff , 1 for family member see 812, two bathrooms (one for clients and one for staff ), living room, office, dining room, TV room, kitchen and covered storage area inaccessible to clients, lounge room for live-in staff member , back yard with shaded area, and home has a attached garage(washer and dryer) inaccessible to clients.

During the visit the Infection control domain was used and the following areas were observed/inspected: The facility had all postings at the front entrance, bathrooms, and throughout the facility. Hand sanitizing gel and masks were located at the entry of each room. A pre screening area with PPE supplies was observed. The facility mitigation plan was reviewed and approved on 04/09/2021. Fire drill completed on 10/01/22.

LPA conducted a complete tour of the facility, and observed the supply of food which has sufficient non-perishable and perishable goods. Client medications, and medication logs were reviewed. The smoke detectors/carbon monoxide detector are operable. LPA observed one fire extinguisher located in the kitchen. The water temperature in the common bathroom was 117.3 and the kitchen sink hot water tested and read at 116.8

There were no deficiencies cited. LPA provided a copy of todays report to Mrs.Tan.

Exit interview conducted.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Ashley Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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