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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800170
Report Date: 09/06/2022
Date Signed: 09/06/2022 12:20:48 PM

Document Has Been Signed on 09/06/2022 12:20 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: 4DATE:
09/06/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Richard Giroud - Assistant AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of following up on the relocation of residents from Benson House #19 (#331880682) to this location due to emergency evacuation orders from a nearby fire. LPA Colvin met with Administrator Richard Giroud and informed him of the purpose of the visit and obtained emergency contact information for each resident. LPA Colvin confirmed that all residents (2) from Benson House #19 were relocated to this facility temporarily, and the facility is now at capacity. Facility has sufficient food and supplies to support their residents as well as the relocated residents, and staff from Benson House #19 brought clothing and other supplies for the residents from their location, and Benson House #19 staff will continue to care for their residents at this location. Administrator Richard Giroud confirmed that emergency file (consumer face sheet, emergency contacts, medication list, and physician's report) was brought to the relocation site, along with residents' medications.

LPA Colvin toured the facility and confirmed that residents are provided comfortable accommodations, and there were vacant rooms available for the residents to use, fully equipped with required bedroom furniture. No immediate health or safety concerns observed at this time. LPA Colvin additionally confirmed ratio for each resident (all 2:1 while in the facility) and that there will be a minimum of 8 staff at the facility while all residents are present. During LPA Colvin's inspection, residents were out of the facility on an outing with the required staff for their ratios when out in the community.

An exit interview was conducted with Administrator Richard Giroud, and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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