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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800416
Report Date: 12/27/2022
Date Signed: 12/27/2022 10:36:52 AM

Document Has Been Signed on 12/27/2022 10:36 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SAN BENITO HOUSEFACILITY NUMBER:
216800416
ADMINISTRATOR:ANN GOUGHERFACILITY TYPE:
735
ADDRESS:6 SAN BENITO WAYTELEPHONE:
(415) 895-1624
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 4DATE:
12/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver #1, Catherine KaranjaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at San Benito House for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver #1, Catherine Karanja and was granted access into the facility. Upon arrival, LPA was checking background clearances and learned via Guardian that Caregiver #2, Donna Joson (See LIC 812) is not background cleared nor associated to the facility (See LIC 809D-Civil Penalty Assessed). Caregiver #2 departed from the facility at 09:49 AM.

LPA and Caregiver #1 toured the facility and found facility to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/22. First aid kit was inspected and found to be appropriate. Facility smoke detectors and carbon monoxide were tested and are working properly during this inspection. Hot water temperature measured 111 degrees F in 2 out of 2 client’s bathroom faucets which is within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked closet in the laundry room. Dangerous items were stored inaccessible to develop disabled clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathrooms designated for clients at the facility were supplied with individual towels; hand soap dispenser was available. There was a supply of perishable and non-perishable foods as required by Title 22 regulation. Food menu was available and visible on the refrigerator. All five client’s bedrooms have lighting and appropriate furnishings.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE. Staff have had all PPE training required and have been N95 Fit tested in April 2022

LPA requested the following documents to be sent to CCL: (Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SAN BENITO HOUSE
FACILITY NUMBER: 216800416
VISIT DATE: 12/27/2022
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LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
LIC 610D-Emergency Disaster Plan
Updated facility sketch
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of Residents

Deficiencies and Civil Penalty are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 1 and the Health and Safety Code. Failure to correct the deficiency and/or repeated deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Caregiver #1. Administrator participated via telephone.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/27/2022 10:36 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 12/27/2022 at 10:26 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SAN BENITO HOUSE
FACILITY NUMBER: 216800416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(a)
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code Section 1522(b) and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 Caregivers is not background cleared, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2022
Plan of Correction
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Plan of Correction shall include associating ALL caregivers that provide care and supervision to clients. In addition, Administrator/Licensee shall provide a written summary on how future compliance will be met.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022


LIC809 (FAS) - (06/04)
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