198603668-1-26-2024-28-AS-KRAZ-CZURDY-20240126115644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603668
Report Date: 01/26/2024
Date Signed: 01/26/2024 11:56:53 AM

Document Has Been Signed on 01/26/2024 11:56 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 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: 3	DATE:	01/26/2024
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Licensee Antonette Tami-ing		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 01/26/2024. LPA was met by Licensed Vocational Nurse- Sebastian Flor and explained the purpose of the visit. This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) and receives services from San Gabriel/Pomona Regional Center. The facility is licensed to serve five (5) developmentally disabled clients ages 18 and above; of which five (5) may be bedridden. During today’s visit, LPA Ramirez observed one (1) Respiratory Therapist, one (1) Licensed Vocational Nurse and two (2) Direct Support Staff.

Kitchen: LPA Ramirez observed appliances to be clean and in working order. LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located kitchen cabinet, to be inaccessible to three (3) out of three (3) clients in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to three (3) out of three (3) clients in care. Signs promoting hand washing were observed in this area. Meal plan was observed in this area for one (1) client in care.

Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Client Rooms 1 - 5: LPA Ramirez observed all resident bedrooms to contain the required linens, furnishings, and lighting. LPA Ramirez observed mechanical lifts in all client bedrooms and were observed to be in working order. LPA Ramirez observed caution signs indicating “oxygen in use” near entry of client rooms where oxygen was in use. Two (2) out of five (5) bedrooms are currently unoccupied. LPA Ramirez observed “treatment cart” in all client bedrooms.

Bathrooms: Water temperature in bathroom#1 was measured at 110.3 degrees F. Bathroom #2 water temperature was measured at 109.4 degrees F. Mechanical lift in bathroom# 2 was operable and tested during visit. LPA Ramirez observed a shower gurney in bathroom #2. LPA Ramirez observed three (3) individually labeled cabinets on nearby wall that contained individual hygiene products for each of the three (3) clients in care. All client bathrooms were observed to be clean and signs promoting hand washing were observed.

SEE 809-C

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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: 01/26/2024

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Laundry Area: LPA Ramirez observed laundry soap and supplies to inaccessible to three (3) out of three (3) clients in care.

Centrally Stored Medications: LPA Ramirez medications cart to be locked and inaccessible to three (3) out of three (3) clients in care.

Backyard: No large bodies of water were observed. Passageways are free of any obstructions. LPA Ramirez observed wheelchair accessible swing for clients in care.

Attached Garage: Generator was observed, and LPA observed generator log with bi-weekly testing. LPA Ramirez observed emergency water, food and disaster supplies in garage.

Emergency Drills: Proof of last documented emergency drill was conducted 12/21/23 during AM shift.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide and smoke detectors in hallways. Smoke detectors were observed to be operable during visit.

Personnel Records: Six (6) personnel records were observed. Administrators Certificate for Leilani Libang with an expiration date of 02/05/25 was observed.

Client Files: Three (3) client files were reviewed.

No deficiencies were cited. Exit interview conducted. A copy of this report was provided.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

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