198602963-10-28-2023-11-AS-PSCT-CX2PFH-20231028111646

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602963
Report Date: 10/28/2023
Date Signed: 10/28/2023 11:16:54 AM

Document Has Been Signed on 10/28/2023 11:16 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	BEN T'S FAMILY CARE		FACILITY NUMBER:	198602963
ADMINISTRATOR:	KIMBERLY LEE		FACILITY TYPE:	735
ADDRESS:	17700 EXA CT		TELEPHONE:	(323) 779-1842
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 4		CENSUS: 3	DATE:	10/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Kimberly Lee		TIME COMPLETED:	12:00 PM

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On 10/28/2023, at 9:00am, Licensing Program Analyst (LPA) Perry Scott made an unannounced inspection to Ben T’s Family Care. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Lupe Ross, House Manager, and Kimberly Lee, Administrator, and the purpose of the visit was explained. The facility is licensed to serve four (4) developmentally disabled clients (age 18-59) of which four (4) may be ambulatory. Currently, the home has (3) clients. The clients are South-Central Los Angeles Regional Center clients. None of the clients have Restricted Health Care Conditions and none utilizes postural supports or protective devices. The facilities’ annual fees are current.

The facility is a 2-story structure with 5 bedrooms, 2 bathrooms, living room, kitchen, office/dining room and a large backyard patio area.

LPA conducted a records review of (3) client records, (4) staff records, (3) clients Personal & Incidental Records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records and did not observe any discrepancies at the time of visit.

At 9:20am, LPA and the House Manager toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly.

Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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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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: BEN T'S FAMILY CARE	FACILITY NUMBER: 198602963
	VISIT DATE: 10/28/2023

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The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 116.4F. A comfortable temperature is maintained in the facility.

LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The fire extinguisher was charged, and the smoke/ carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 10/17/2023.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE).

LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

During today’s visit there were no deficiencies observed.

Exit interview held. A copy of the report was provided to Kimberly Lee, Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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