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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800170
Report Date: 11/12/2024
Date Signed: 11/12/2024 05:16:00 PM

Document Has Been Signed on 11/12/2024 05:16 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENSON HOUSE INC 14FACILITY NUMBER:
331800170
ADMINISTRATOR/
DIRECTOR:
CATHERINE M. OMR, RBT.FACILITY TYPE:
738
ADDRESS:26589 CALIFORNIA AVETELEPHONE:
(951) 467-0649
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY: 4CENSUS: 2DATE:
11/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:07 PM
MET WITH:Catherine Omar-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Debbie Palacios made an unannounced visit to conduct a case management visit for Client 1 (C1)’s death. LPA conducted a health and safety check and met Program Administrator, Catherine Omar and Acting Administrator Rolanda Henderson and explained the purpose of today’s visit. At the time of the LPA’s visit, there was 2 (two) clients at the facility and 5 (five) staff members present at the time of the visit.

During the LPA’s visit, LPA reviewed, requested, and obtained copies of pertinent documentation, conducted staff interview with staff member 1 (S1) regarding C1’s death on 11/10/24. LPA interviewed to obtained further information regarding the death of C1 and the events that led up to C1’s death. LPA was not able to interview the 3 (three) staff who were present due to taking worker's comp. Administrator stated that they were emotionally impacted by the events since they were present at the time of the incident. LPA obtained the contact information of the 3 (three) staff members. The cause of death is due to a car impact; staff reported that the alleged driver was driving under the influence. LPA advised Administrator, Catherine Omar and Acting Administrator Rolanda Henderson to send a copy of the death certificate to the department, as soon as it becomes available.

No deficiencies were cited during this visit, as there were no health and safety concerns observed during today's visit.

An exit interview was conducted and a copy of this report (LIC 809) and LIC 811 (confidential names list) were provided to Administrator, Catherine Omar.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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