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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800170
Report Date: 08/15/2022
Date Signed: 08/15/2022 11:45:13 AM

Document Has Been Signed on 08/15/2022 11:45 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, 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: 1DATE:
08/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:ASSISTANT ADMINISTRATOR, DOLORES CESPEDESTIME COMPLETED:
11:48 AM
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On August 15, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Assistant Administrator, Dolores Cespedes. LPA Mixson met with Assistant Administrator introduced self and stated the purpose of the visit.

Present in the facility were 1 resident and 3 caregivers. There are currently no cases of COVID-19 within the facility.

LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Administrator.

An exit interview was conducted and a copy of this report, along with the LIC 811, was provided to Assistant Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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