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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800170
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:18:44 PM

Document Has Been Signed on 10/21/2021 03:18 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENSON HOUSE INC 14FACILITY NUMBER:
331800170
ADMINISTRATOR:BERTHA MARTINFACILITY TYPE:
738
ADDRESS:26589 CALIFORNIA AVETELEPHONE:
(951) 467-0649
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 2DATE:
10/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Administrator, Bertha MartinTIME COMPLETED:
03:20 PM
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On 10/21/2021 LPA Cuevas codncuted and unannounced visit to the facility to follow up with reported concerns that Resident # 1 (R1) was observed being lethargic and sleeping during school hours. LPA was provided with MAR's records,incident reports, and physicians report.

Review of documents identify residents to be receiving medication management by both a psychiatrist and primary physician. Furthermore, during visit LPA was informed that R1 was recently hospitalized on 10/20/21 due to school reporting concerns for over being medicated. Reviewed documents from hospital discharge documents reveals that lab work was done, bwork identifies reading to be within range. R1, was discharged the same day back to the facility.

Per interviews with staff it was communicated that R1's enrollment in school has been a difficult adjustment as R1 was not use to the routine and school rules. Facility has made attempts to move R1 to a school more suitable for his behaviors; However, per facility staff school district wanted to try regular setting before considering other school cites. Staff reports R1 to demonstrate behaviors of shutting down and not paying attention when not feeling like engaging with other, this may have been misinterpreted as defiance; however, per facility when R1 comes home from school R1 returns to base line behaviors of engaging with others and being energetic.

No concerns observed during todays visits.

An exit interview was done with Administrator, Bertha Martin were this report was reviewed and provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: David Cuevas
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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