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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603668
Report Date: 06/23/2023
Date Signed: 06/23/2023 10:38:55 AM

Document Has Been Signed on 06/23/2023 10:38 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENEVOLENT HOMEFACILITY NUMBER:
198603668
ADMINISTRATOR:LIBANG, LEILANI T.FACILITY TYPE:
734
ADDRESS:1837 ROSEMOUNT AVE.TELEPHONE:
(909) 841-6315
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 5CENSUS: 2DATE:
06/23/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Leilani Libang - AdministratorTIME COMPLETED:
10:40 AM
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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. This is the 2nd Pre-Licensing visit LPA has done thus far for this new 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 is a locked storage area that is centrally located for medication.

· Cleaning supplies are kept separate from food and located in a locked cabinet under the kitchen sink.

· Facility walls, ceilings, floors, window screens and areas around the facility are clean and in good repair.

· Fire extinguishers and smoke detectors operate properly.

· Doors and passageways are free of obstruction.

· There are no pools/bodies of water at the facility.

· Facility does not have firearms on premises.

· Facility sketch and sample menus.

(Continued on 809-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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: 06/23/2023
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· There is an emergency exiting plan with emergency phone numbers posted.

· Facility has a current disaster and mass casualty plan maintained at the facility.

· There is a plan for employee accommodations and staffing arrangements.

· Operating telephone is on the premises and will be available to clients.

· Vehicles to transport clients are maintained and in operation condition.

· Client Records were observed and have all the appropriate documents/records in their file.

· First-aid supplies are maintained and readily available.

· Refrigerator and freezer were observed and are maintained at the correct temperatures.

· Food storage and preparation are clean and appropriate for food preparation.

· Hot water temperature was tested and is within the required range of 105-120 degrees F.

Component III was completed at the previous Pre-Licensing visit dated 5-31-23.

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: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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