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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602963
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:45:17 PM

Document Has Been Signed on 08/23/2024 03:45 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:BEN T'S FAMILY CAREFACILITY NUMBER:
198602963
ADMINISTRATOR/
DIRECTOR:		KIMBERLY LEEFACILITY TYPE:
735
ADDRESS:17700 EXA CTTELEPHONE:
(323) 779-1842
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY: 4CENSUS: DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:21 AM
MET WITH:Lupe RossTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 08/23/2024, at 10:16am, Licensing Program Analyst (LPA) Zina Brown 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 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 (2) 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 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 (2) client records, (3) staff records, (1) client 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 (2) Client Medication Administration Records and did observed a discrepancy for client #1. For client #1 medication log for the month July was filled out her, medication was still in the packing for July 23 - July 31. LPA asked house manager Lupe Ross to clarify discrepancy and Lupe Ross was unable to provide reason for discrepancy.

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Report continued on LIC809-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BEN T'S FAMILY CARE
FACILITY NUMBER: 198602963
VISIT DATE: 08/23/2024
NARRATIVE
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At 10:25am, LPA and the House Manager Lupe Ross 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.

The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 114.5F (downstairs bathroom) and 108.5 (upstairs bathroom). Bathrooms were found to not be within Title 22 regulations. LPA observed bathroom #2 the sink had some form residue and the lighting had rust that needs to be clean.

LPA observed the facility and it is 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. Also, LPA observed in the dining area and kitchen floors and discovered cracks in the floor that need to be repaired.

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 07/07/2024

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that the facility had the required postings, posted throughout the facility.

Deficiencies were sited under California Code of Regulations Title 22, Division 6, Chapter 1 & 6.

Exit interview held. A copy of the report was provided to Lupe Ross, House Manager.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 08/23/2024 03:45 PM - It Cannot Be Edited


Created By: Zina Brown On 08/23/2024 at 01:28 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEN T'S FAMILY CARE
FACILITY NUMBER: 198602963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the LPA observe the medication administration record for July 2024 which staff check off that client #1 received medication (Cholecalciferol) from July 23 - 31 but LPA observed that medication bubble pack for date of July 23 - 31 were not empty, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2024
Plan of Correction
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The licensee and staff will complete medication training by POC due date and submit proof of training by email: zina.brown@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/23/2024 03:45 PM - It Cannot Be Edited


Created By: Zina Brown On 08/23/2024 at 01:28 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BEN T'S FAMILY CARE
FACILITY NUMBER: 198602963

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based observation, bathroom #2 the sink had some form residue and the lighting had rust that needs to be clean.the licensee did not comply with the section cited above in with the section cited above in which poses an immediate health and safety rights to clients in care.
POC Due Date: 09/06/2024
Plan of Correction
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The licensee will clean the sink and lighting fixture in bathroom #2 and will repair the cracked floor in the dining area/kitchen by correction by the due date and submit photo proof by email: zina.brown@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Janae Hammond
LICENSING EVALUATOR NAME:Zina Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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