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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880610
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:58:38 AM

Unsubstantiated


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
10/02/2024 and conducted by Evaluator Kathleen Banrasavong
COMPLAINT CONTROL NUMBER: 18-AS-20241002143525
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: 4DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Adebayo A. FijabiTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Facility staff pinched client
INVESTIGATION FINDINGS:
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 Licensing Program Analyst, (LPA) Kathleen Banrasavong conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA met with Administrator, Adebayo A. Fijabi, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of observation, interviews with staff members and residents, and records review.
On October 2, 2024, Community Care Licensing received a complaint alleging, facility staff pinched client. It was alleged that on August 25, 2024, Client 1 (C1) was pinched by Staff 1(S1). LPA interviewed Administrator and it was reported that the facility conducted an internal investigation. During the investigation, S1 denied pinching R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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 4
Control Number 18-AS-20241002143525
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: 10/22/2024
NARRATIVE
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S1 stated that during the incident only verbal redirection was provided. This information was obtained from S1's exit interview. It was advised by the Administrator that the investigation was concluded, when S1 voluntarily resigned. Information obtained from interview with staff members at the facility stated there was an incident that occurred at the facility on the alleged date, but there were no issues of concerns brought up or addressed. Information obtained from interviews with residents indicated there were no issues or concerns with staff members being physical while redirecting residents. LPA was unable to interview S1 and additional pertinent witnesses due to S1 not responding to the LPA’s requested interview.

Based on the information obtained during the investigation and the inability to obtain contact with S1 and additional witnesses, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore, the allegation is unsubstantiated.

An exit interview was conducted and a copy of this report was discussed with and provided to Administrator, Adebayo A. Fijabi.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4