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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336411349
Report Date: 02/28/2024
Date Signed: 02/28/2024 04:26:37 PM

Document Has Been Signed on 02/28/2024 04:26 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
02/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:19 PM
MET WITH:AL Ortiz/ManagerTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts, Bianca Wolcott, (LPA Wolcott) & Javier Prieto, (LPA Prieto) conducted an unannounced visit to initiate a case management incident. LPA met with AL Ortiz and Brenda Ybarra (Lead), and explained the nature of the visit.

LPAs Wolcott & Prieto, interviewed staff and residents. LPA toured facility and collected pertinent information. LPAs Wolcott & Prieto, advised Administrator that additional time will be needed to conduct additional interviews and review collected information, therefore this complaint will need further investigation.

At time of visit, there were no health or safety concerns observed.

An exit interview was conducted where this report was discussed, reviewed, then provided to AL Ortiz (House Manager)

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Bianca Wolcott
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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