<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603668
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:02:51 PM

Document Has Been Signed on 07/23/2024 01:02 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 HOMEFACILITY NUMBER:
198603668
ADMINISTRATOR/
DIRECTOR:		LIBANG, LEILANI T.FACILITY TYPE:
734
ADDRESS:1837 ROSEMOUNT AVE.TELEPHONE:
(909) 841-6315
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY: 5CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:41 AM
MET WITH:Administrator Leilani LibangTIME VISIT/
INSPECTION COMPLETED:
01:00 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) Kimberly Ramirez conducted an unannounced Annual Required Visit on 07/23/2024. LPA was met by Licensed Vocational Nurse- Ernesto Aductante and explained the purpose of the visit. Administrator Leilang Libang. Arrived shortly after to assist with tour. 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.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to clients, were observed to be inaccessible to clients. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) client rooms. All client bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observe postings encouraging proper handwashing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. 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. One (1) out of the five (5) client bedrooms is currently unoccupied.

See 809-C.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 2
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: 07/23/2024
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
26
27
28
29
30
31
32
Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C).

Client Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Last documented emergency drills were conducted on 06/11/2024 & 05/17/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply.



Health Related Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) electronic log to document medications given. The facility provides incidental medical services.

Staffing: Administrator Certificate for Leilani T Libang expires 02/05/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed.

Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.



Operational Requirements: The fire clearance is approved for five (5) non-ambulatory of which five (5) may be bedridden.

Clinet Records/Incident Reports: LPA reviewed client files for four (4) clients. Client files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights and Individual Personal Plan (IPP) were observed.

No deficiencies were cited during this inspection. Exit interview was conducted. A copy of this report was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2