198601970-9-26-2023-28-AS-THEA-CW2T62-20230926142624

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198601970
Report Date: 09/26/2023
Date Signed: 09/26/2023 02:26:30 PM

Document Has Been Signed on 09/26/2023 02:26 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:	BENOR HOME		FACILITY NUMBER:	198601970
ADMINISTRATOR:	LOLITA TAN		FACILITY TYPE:	735
ADDRESS:	13439 FLATBUSH AVENUE		TELEPHONE:	(562) 864-7814
CITY:	NORWALK	STATE: CA	ZIP CODE:	90650
CAPACITY: 2		CENSUS: 1	DATE:	09/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:02 PM
MET WITH:	Dave Mendoza (Caregiver)		TIME COMPLETED:	02:43 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced visit for an Annual Inspection. Upon arrival, LPA met with Dave Mendoza (Caregiver) and explained the purpose for the visit. The facility is licensed to serve 2 Non-Ambulatory Developmentally Disabled Adults Ages 18-59 years old. The facility is a single-story home located in a residential area in Norwalk, Ca. A tour of the facility includes: 2 Client Bedrooms, 2 Staff Bedrooms, 1 Private Bedroom (see 812), 2 bathrooms (one is inside staff room), Office Area, Living Room, Dining Area, Kitchen, Front Yard, and Attached Garage. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: Client bedrooms had the required furniture for comfort and safety and had sufficient lighting. All outdoor passages were free of obstruction. Bathroom was clean, toilet and water faucet worked properly. Water temperature was measured in client bathroom and was within the required range of 105 – 120 Degrees F. Client bath towels, toiletries and personal hygiene supplies were adequately available. All storage areas for cleaning solutions, toxins, knives, and hazardous items are securely stored and inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed to be fully charged. Operational Requirements: The facility has the appropriate fire clearance. The last Fire/Emergency Drill was conducted on 09/01/23. There was no outdoor activity area with required shade and outdoor furnishing (this will be cited on 809-D). Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Lolita Tan’s certificate expires on 01/17/2024. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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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Document Has Been Signed on 09/26/2023 02:26 PM - It Cannot Be Edited

Created By: Tena Herrera On 09/26/2023 at 01:59 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: BENOR HOME	FACILITY NUMBER: 198601970
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85087.2(b)

Outdoor Activity Space

(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as licensee could not furnish proof of required shading and furnishing for outdoor use, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/10/2023
	Plan of Correction
1 2 3 4	Licensee stated will purchase items to meet the requirement of shaded area and furinishing for outdoor use. Licensee will provide receipt of items to meeet this requirement and submit copy to LPA via email by POC due.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

David Sicairos

LICENSING EVALUATOR NAME:

Tena Herrera

LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENOR HOME	FACILITY NUMBER: 198601970
	VISIT DATE: 09/26/2023

NARRATIVE

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Personnel Records-Training: Staff has criminal record clearance. Staff have current CPR/first aid training along with sufficient on-going training.
Client Rights-Information: Facility provides internet and telephone access for the clients in care.
Client Records-Incident Reports: Client file is maintained in a secured cabinet within the Office Area, client file has the following documents – Admission Agreement, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Services: Medications for residents are securely stored in a locked cabinet. All medication observed during visit were properly labeled and in their original containers.
Incidental Medical & Dental: Staff designated to administer medication has the proper annual training on file.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Emergency Intervention: Residents at this facility do not require the use of restraints or the use de-escalation techniques.

LPA conducted 2 staff interviews and 0 client interviews during today’s visit.
LPA reviewed 3 staff files and 1 client file during visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during the visit are documented on 809D.

Exit interview was held and a copy of the report was provided to Caregiver Dave Mendoza.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023

LIC809 (FAS) - (06/04)

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