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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880610
Report Date: 02/23/2024
Date Signed: 02/23/2024 11:39:21 AM

Document Has Been Signed on 02/23/2024 11:39 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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:
02/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Adebayo FijabiTIME COMPLETED:
11:45 AM
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On 2/23/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced to conduct a required annual inspection at the facility. LPA met with Administrator, Adebayo Fijabi who was informed of the purpose of the visit. During today's visit there were four (4) staff and two (2) clients present and LPA was informed that two (2) clients were out in the community.

The facility has a fire clearance for four (4) non-ambulatory clients and serves adults ages 18-59. LPA conducted a tour of the facility and staff and client interviews, and observed the following:

Facility staff tested the smoke alarms and carbon monoxide detectors and LPA found them to be operational. LPA observed charged fire extinguished last serviced on 9/6/2023, mounted throughout the facility. LPA toured the kitchen and observed the facility has more than a 2-day supply of perishable food and 7-day supply of non-perishable foods. Medication and sharps are secured in the laundry room. The facility has emergency food and water stored in the garage. LPA also observed four (4) backpacks with emergency supplies for the clients in care. The facility is clean and free of odors. LPA reviewed random staff and client files. Staff files reviewed had the required training documentation and valid first aid certification. Client files had updated Individual Program Plans and signed Admission Agreements. The facility safeguards clients' cash resources. LPA reviewed the Record of Client's/Resident's Safeguarded Cash Resources (LIC 405) along with the physical monies for two (2) clients and did not discover any discrepancies. During today's visit, LPA did not observe any deficiencies. An exit interview was conducted and a copy of this report was reviewed and provided to Administrator, Fijabi.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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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