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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800170
Report Date: 08/01/2024
Date Signed: 08/01/2024 10:55:21 AM

Document Has Been Signed on 08/01/2024 10:55 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/
DIRECTOR:		DELORES CESPEDESFACILITY TYPE:
738
ADDRESS:26589 CALIFORNIA AVETELEPHONE:
(951) 467-0649
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 3DATE:
08/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:ADMINISTRATOR, CATHY OMRTIME VISIT/
INSPECTION COMPLETED:
10:58 AM
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On August 01, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced to conduct the Required Annual Inspection and met with the Administrator, Cathy Omr. The facility file review was conducted at the Regional Office and additional records were requested and reviewed on site. The facility is licensed for four Adult (738) and is currently operating at a capacity of three Adults.

The facility is a single story home with four bedrooms and three bathrooms and an attached garage. The facility is designated as a Crisis Home and the Residents served are Adults between the ages of 18-59. LPA Mixson conducted a tour of the facility inside and out, reviewed facility documents and conducted interviews following is a summary of visit.

Infection Control: LPA Mixson observed hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs, along with personal hygiene items and equipment used for cleaning.

Physical Plant: LPA Mixson observed resident bedrooms and staff office. Physical plant, floors, windows, and doors were clean and fixtures and furniture were in good repair. The facility's outdoor area was free of hazards and contained outdoor furniture and shaded area for outdoor activities and family visits. Laundry equipment was in good working condition currently at the time of this visit. The sharp items and cleaning solutions were locked and inaccessible to residents in care. The smoke detectors and carbon monoxide detectors were observed and operational, and the hot water temperature tested within regulations.

Food Service: LPA Mixson observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required two day supply of perishable and seven day supply of non-perishable foods.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BENSON HOUSE INC 14
FACILITY NUMBER: 331800170
VISIT DATE: 08/01/2024
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Care & Supervision/Administration: Adequate staff are present for the care and supervision at the time of this visit. LPA Mixson reviewed staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were observed posted throughout the facility. The Administrator's certification is in the process of being updated.

Record Review and Resident/Staff Files: LPA Mixson reviewed staff files, training, and files were seen to contained staff criminal clearance and updated training along with CPR/First Aid/CPI Certification. Resident files were reviewed and possessed required paperwork currently at the time of this visit. LPA Mixson reviewed residents funds, along with Administrator there were no discrepancies or concerns currently.



Health Related Services/ Incidental Medical Services: Medications were locked and inaccessible to the residents in care in the laundry room. LPA Mixson reviewed client medications and reviewed medications listed on medication administration report and required labeling was observed with no concerns at this time.

Disaster preparedness: LPA Mixson reviewed the facility's emergency and disaster plan and reviewed documentation showing the facility holds monthly fire and earthquake drills, which was last conducted on 07/25/204, which met the department requirements. LPA observed facility exits were clear from obstructions and/or debris. LPA Mixson reviewed emergency supplies in the garage, along with the first aid kit with required items.

There were no Title 22 Division 6 Regulations cited or observed at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Administrator, Cathy Omr.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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