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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602963
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:19:23 AM

Document Has Been Signed on 09/29/2022 10:19 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BEN T'S FAMILY CAREFACILITY NUMBER:
198602963
ADMINISTRATOR:WILLIAMS, MARLONFACILITY TYPE:
735
ADDRESS:17700 EXA CTTELEPHONE:
(323) 779-1842
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: 2DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lupe RossTIME COMPLETED:
10:30 AM
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On 09/29/22, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced Annual required visit, with a primary focus on infection control measures. LPA Scott was met by Lupe Ross, house manager, and the purpose of today’s visit was explained. The facilities annual fees are current.

The facility is licensed to serve four (4) adults age 18 to 59 years old. There are currently 2 residents in care: all ambulatories. The facility is a 2-story structure with 5 rooms and 2 bathrooms, living room, kitchen, office/dining room and a large backyard patio area. LPA Scott and Ms. Ross toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. Fire extinguisher was charged.

All client rooms were checked and are in good condition, adequate lighting provided, storage for client personal belongings was observed. There is an adequate supply of PPE stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. LPA observed the facility to be adequately clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were not accessible to clients. Smoke/Carbon detectors are operational.

During the visit, LPA observed the facility infection control practices. LPA did observe screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (cdss.ca.gov) for Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there were no deficiencies.

Exit interview held and a copy of the Facility Evaluation Report was provided to House Manager Lupe Ross.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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