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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336412350
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:50:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/06/2022 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220906112811
FACILITY NAME:BENSON HOUSE, INC #9FACILITY NUMBER:
336412350
ADMINISTRATOR:AURORA ARZATEFACILITY TYPE:
735
ADDRESS:68615 VISTA CHINOTELEPHONE:
(760) 327-3715
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY:4CENSUS: 4DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Administrator Alexis ParkerTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee does not ensure resident's beds have clean mattresses.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA was met with Administrator Alexis Parker and conducted a tour of the facility. LPA initiated the investigation into the above allegation; LPA conducted staff interviews, resident interviews, reviewed records and took copies of pertinent information. Administrator Erica Mata arrived inside the facility during the visit.

Regarding the allegation, "Licensee does not ensure resident's beds have clean mattresses," It was reported that under the cover of the personal mattress of Resident One (R1) was covered in rust, and mold due to the fact that the individual has incontinence issues.

**Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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 3
Control Number 18-AS-20220906112811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BENSON HOUSE, INC #9
FACILITY NUMBER: 336412350
VISIT DATE: 09/14/2022
NARRATIVE
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LPA inspected the mattress in Room #1, and found that the mattress had a urine smell, as well as a rust color on the bottom of the mattress. When LPA lifted up the mattress, LPA observed a sunken spot with a "spring" protruding from the box spring into the mattress. Upon inspection of Room #2, LPA found the mattress to be in overall good shape other than the mattress cover had a tear. In Room #3, LPA observed a sunken "bowed" appearance in the box spring. Room #4 had a sunken spot in the middle of the mattress that was very pronounced. Resident (R4) complained of being "poked" when they sat on the mattress. Based on these observations, coupled with interviews conducted, LPA determined the preponderance of the evidence standard has been met, and therefore the complaint is SUBSTANTIATED.

An exit interview was conducted, where a copy of this report was discussed with and provided to Ms. Parker along with copies of the LIC9099-C, LIC9099-D, and Appeal Rights.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220906112811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENSON HOUSE, INC #9
FACILITY NUMBER: 336412350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited
CCR
85088(c)(1)
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Fixtures, Furniture, Equipment and Supplies. (c) The licensee shall ensure provision to each client..(1) An individual bed..in good repair..This requirement was not being met as evidenced by:
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Licensee states that the mattresses not in good repair will be replaced 9/14/22 and will submit receipts to LPA by POC date. Licensee also states that in-service training will be conducted to inspect for mattress deficiencies, as well as a review of the regulation and submit to LPA by POC date.
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Based on observation, and interview, R1, R2, and R3's mattresses need replacing. Licensee did not adhere to the regulation. This presents a potential health and safety and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3