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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880610
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:21:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230926092153
FACILITY NAME:BENSON HOUSE INC #16FACILITY NUMBER:
331880610
ADMINISTRATOR:ADEBAYO A. FIJABIFACILITY TYPE:
737
ADDRESS:222 CAMINO LOS BANOSTELEPHONE:
(951) 487-0350
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:4CENSUS: 3DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Adebayo Fijabi, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff engaged in a physical altercation with a client.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Adebayo Fijabi, and informed him of the purpose for her visit.

The investigation included staff/client interviews, records review, and records collection.

A report was received by the Department alleging Staff One (S1) threw Client One (C1) on the ground during a physical altercation and restrained the client by the hands and wrists. A Serious Incident Report (SIR) revealed a physical altercation did take place between C1 and S1 on 09/24/2023. Video surveillance was reviewed by the LPA. C1 was observed to start an altercation by attempting to hit S1 with a closed fist before the two individuals move out of the frame. When C1 and S1 moved into a new frame S1 was observed to have their arm around C1's neck as the staff stood from behind. The surveillance showed S1 move C1 toward the ground, though, it could not be determined if S1 threw C1 to the ground. Surveillance continued to show S1 fall over
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20230926092153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #16
FACILITY NUMBER: 331880610
VISIT DATE: 10/04/2023
NARRATIVE
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and land on top of C1, where the staff remained for several minutes. No staff interviews reported S1 threw C1 to the ground.

Staff interviews reported S1 did restrain C1 by holding the client's arms above their head. S1 was contacted; the staff agreed to provide a statement regarding the incident, though one was not received prior to the conclusion of the visit.

Two observation/Information Reports revealed C1 sustained injuries. One document reported C1 was observed on 09/24/2023 with two small cuts to the left hand and another document reported C1 was observed on 09/25/2023 with two bruises on the inner biceps of both arms and multiple scratches on the upper back.

C1 was interviewed and confirmed they initiated the physical altercation with S1 by punching the staff in the face. C1 reported they (C1) and S1 were pushing each other, and they both fell on the ground. C1 reported S1 was grabbing their biceps and caused bruising near their upper arms, which was observed by the LPA.

According to Administrator Fijabi and the facility's Emergency Intervention Support Plan, S1 did not utilize proper training techniques when attempting to de-escalate the incident between themself and C1. In addition, staff who were present at the facility did not intervene to provide the staff support.

A Crisis Prevention Intervention (CPI) Training Log revealed S1 did receive training on de-escalation techniques on 09/22/2023. The Department also received a Report of Suspected Dependent Adult/Elder Abuse (SOC 341) the day following the incident.

Based on records and interviews, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted; this report was reviewed with Administrator Fijabi and a copy was provided, along with LIC 811 and appeal rights.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20230926092153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #16
FACILITY NUMBER: 331880610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/04/2023
Section Cited
CCR
80022(k)
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PLAN OF OPERTATION: (k): The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement was not met, as evidenced by: Based on records and interviews, the Licensee did not ensure the facility's Plan of Operation was followed
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S1 was terminated on 09/25/2023. In-service training was provided to staff who were present during the incident and proof was obtained. This POC is cleared.
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during an incident between C1 and S1. According to the Administrator & the facility's Emergency Intervention Support Plan, S1 did not utilize proper training techniques when attempting to de-escalate the incident between themself & C1. This posed a potential threat to the client in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/26/2023 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20230926092153

FACILITY NAME:BENSON HOUSE INC #16FACILITY NUMBER:
331880610
ADMINISTRATOR:ADEBAYO A. FIJABIFACILITY TYPE:
737
ADDRESS:222 CAMINO LOS BANOSTELEPHONE:
(951) 487-0350
CITY:SAN JACINTOSTATE: CAZIP CODE:
92583
CAPACITY:4CENSUS: 3DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Adebayo Fijabi, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
4
5
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9
Staff verbally threatened client during an altercation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to start the investigation into the above allegation. The LPA met with Administrator, Adebayo Fijabi, and informed him of the purpose for her visit.

The investigation included staff/client interviews, records review, and records collection.

A report was received by the Department alleging Staff One (S1) made a statement threatening Client One (C1) during a physical altercation on 09/24/2023. C1 was interviewed and stated they (C1) started a physical altercation with S1 by punching the staff in the face. The client stated S1 made a statement to them (C1), saying, "who wants to get a black eye". Staff who were present during the altercation were interviewed; no reports were received to indicate S1 made a statement to C1 about giving the client a black eye. S1 was contacted; the staff agreed to provide a statement regarding the incident, though one was not received prior to the conclusion of the visit. Therefore, due to a lack of information, this allegation is deemed
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20230926092153
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 #16
FACILITY NUMBER: 331880610
VISIT DATE: 10/04/2023
NARRATIVE
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UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

This report was reviewed with Administrator Fijabi and a copy was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Stephanie Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5