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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880682
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:02:47 PM


Document Has Been Signed on 01/23/2024 05:02 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 #19FACILITY NUMBER:
331880682
ADMINISTRATOR:RICHARD GIROUDFACILITY TYPE:
737
ADDRESS:41218 CREST DRTELEPHONE:
(951) 392-3682
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:4CENSUS: 3DATE:
01/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Corey Spight, Incoming Administrator TIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to follow up on a Special Incident Report (SIR) received on 01/16/2024. The LPA met with Incoming Administrator, Corey Spight, and informed him of the purpose for the visit.

The SIR revealed that on 12/29/2023, during a behavioral episode involving Client One (C1), Staff One (S1) held up a chair at the client and stated, "it's okay. I'm crazy too...". The SIR and staff interviews revealed C1 was being supervised by S1 and Staff Two (S2) on 12/29/2023 when the client began to be physically aggressive. Interviews reported C1 could not be de-escalated and began throwing items (a shoe, towels, and a clothing basket) at S1. Staff and client interviews were conducted. Additional time is needed to conduct further interviews. Appropriate follow up will be conducted if the Department finds a violation has occurred.

Due to Incoming Administrator Spight leaving prior to the conclusion of the LPA's visit, the report was reviewed with Administrator Assistant, Alicia Beccue, and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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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