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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411349
Report Date: 11/27/2023
Date Signed: 11/30/2023 03:50:36 PM

Document Has Been Signed on 11/30/2023 03:50 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BENSON HOUSE #7FACILITY NUMBER:
336411349
ADMINISTRATOR:ORALIA WILLIAMSFACILITY TYPE:
735
ADDRESS:910 RIVER DRIVETELEPHONE:
(951) 279-0366
CITY:NORCOSTATE: CAZIP CODE:
92860
CAPACITY: 4CENSUS: 3DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jasmine Gonzalez, House ManagerTIME COMPLETED:
03:00 PM
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1245: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry.

1300: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. P&I records were reviewed and accurate.

1430: Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 105 degrees F. Grab bars, non slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The facility has a posted menu and adequate food stores.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: BENSON HOUSE #7
FACILITY NUMBER: 336411349
VISIT DATE: 11/27/2023
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1345: Personnel Records/Training/and Staffing-. LPA reviewed employee record for first aid certification, finger print clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, last done so on 01/2023 The facility is conducting emergency disaster drills, last done on 11/01/2023..

One client interview was conducted.

Two Staff interviews were conducted.

Based on the information received during this visit today, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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