198603668-5-31-2023-28-AS-THEA-CSCT33-20230531142139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603668
Report Date: 05/31/2023
Date Signed: 05/31/2023 02:22:22 PM

Document Has Been Signed on 05/31/2023 02:22 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:	BENEVOLENT HOME		FACILITY NUMBER:	198603668
ADMINISTRATOR:	LIBANG, LEILANI T.		FACILITY TYPE:	734
ADDRESS:	1837 ROSEMOUNT AVE.		TELEPHONE:	(909) 841-6315
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY: 5		CENSUS: 2	DATE:	05/31/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:31 AM
MET WITH:	LEILANI LIBANG		TIME COMPLETED:	02:30 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 announced pre-licensed visit and met with Administrator Leilani Libang for the purpose of conducting a Pre-Licensing Inspection / Component III visit. This Pre-Licensing Inspection is due to change of ownership. The facility has an approved fire clearance to be licensed to serve five (5) bedridden clients. The facility is a single story home: 5 bedrooms, 2 bathrooms, dining/ living room, backyard with two locked tool sheds, and attached garage located in Claremont, CA. The physical plant was toured inside and out alongside Leilani Libang. Pre-Licensed Inspection Tool was used. The following was observed/inspected · There are 2 bedrooms that currently occupied and are equipped with one bed, night-stand, chair, sufficient lighting, appropriate closet, drawer space and have the required bedding/linen. Remaining 3 bedrooms are missing bedding and one of the three is missing a bed. · Bedrooms are large enough to allow for easy passage between and comfortable for usage of beds and other required items of furniture. · Sufficient supply of linens available to permit weekly changing are available. · Sufficient personal hygiene supply available. · Laundry machine (wash/dryer) observed. · The 2 bathrooms have working toilets/wash basin, and shower. One shower needs to be cleared of boxes and equipment, non-slip mat is also needed. · Smoke Detectors and Carbon monoxide detectors are interconnected approved in the Fire Clearance. · Two (2) Fire extinguishers observed and charged. · Cleaning solutions and sharps need to be locked and stored separately. · Kitchen cabinets, refrigerator/freezer, oven, microwave, dishwasher are in working condition, clean and sanitary. (Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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

FACILITY NAME: BENEVOLENT HOME	FACILITY NUMBER: 198603668
	VISIT DATE: 05/31/2023

NARRATIVE

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· Sufficient dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair.
· Sufficient dining space is available for 5.
· There is a designated medication cart and closet for Medications to be locked and inaccessible to clients.
· Client and Staff files will be stored and locked in a designated file cabinet.
· Physical plant is in good repair.
· Building and grounds are well kept, debris from side entrance needs to be cleared out
· Window screens are in good condition.
· There is a shaded area provided in the backyard to accommodate clients, no bodies of water observed.
· Hot water temperature measured between 107.8 and 114.9 and is within Title 22 regulation.
· The residence is equipped with central air and heating, temperature remains at comfortable temp.
· Facility has telephone and internet line operable, Facility phone number is 909-445-1722.
· Licensee reports no guns or weapons in the home.

Component III was also completed at the time of the visit and all required documents for Licensing were discussed. Facility did not meet the physical plant requirements/ inspection as required per California Code of Regulations Title 22 Division 6.

The following Corrections need to be made prior to clearing the physical plant:

· Bedroom # 5 door handle needs to be repaired on door leading to back yard

· Side entrance needs to be cleared of debris
· Sharps need to be stored in locked area, inaccessible to clients in care
· First aid kit with manual needed
· Documents for personnel records need to be accessible with proper information
· Client Records must have admission agreement
· Sample Menus for one calendar week
· Visiting Policy Posted
(Continued on 809C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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: BENEVOLENT HOME	FACILITY NUMBER: 198603668
	VISIT DATE: 05/31/2023

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· "No Smoking-Oxygen in use" signs posted
· Disaster and Mass casualty plan
· Extra linen needs to be centrally stored
· Bathroom #1 needs to be cleared of stored items in shower and non-slip shower mat is needed
· Bathroom #1 storage area needs to be clear of clients food (liquid food was observed to be stored in closet)
· Food for 7 days non-perishable and perishable
· Bedrooms 2, 4 and 5 need to be cleared of files/boxes
· Bedroom 2 needs bed
· Bedrooms 2, 4 and 5 need proper bedding/linens and pillows on beds.

An exit interview was conducted, and a copy of this report has been furnished to Administrator Leilani Libang. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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