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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601970
Report Date: 08/15/2024
Date Signed: 08/15/2024 10:13:41 AM

Document Has Been Signed on 08/15/2024 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENOR HOMEFACILITY NUMBER:
198601970
ADMINISTRATOR/
DIRECTOR:		LOLITA TANFACILITY TYPE:
735
ADDRESS:13439 FLATBUSH AVENUETELEPHONE:
(562) 864-7814
CITY:NORWALKSTATE: CAZIP CODE:
90650
CAPACITY: 2CENSUS: 1DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:47 AM
MET WITH:Dave Mendoza (Caregiver)TIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Tyler Reyes 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, 2 bathrooms (one is inside staff room), Office Area, Living Room, Dining Area, Kitchen, Front Yard, and Attached Garage. Licensee's son lives at facility and does not receive assistance from facility caregivers. LPA Reyes reviewed Licensee's son clearance on Facility Personnel Report and observed Licensee's son receives assistance from his own personnel care staff.

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 08/01/24.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Lolita Tan’s certificate expires on 05/17/2024.
(Continued on 809-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BENOR HOME
FACILITY NUMBER: 198601970
VISIT DATE: 08/15/2024
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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.


There were no deficiencies cited.

Exit interview was held and a copy of the report was provided to Caregiver Dave Mendoza.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Tyler Reyes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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