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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412351
Report Date: 03/06/2024
Date Signed: 03/06/2024 11:55:30 AM

Document Has Been Signed on 03/06/2024 11:55 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENSON HOUSE, INC #10FACILITY NUMBER:
336412351
ADMINISTRATOR:AURORA ARZATEFACILITY TYPE:
735
ADDRESS:68215 CORTA RD.TELEPHONE:
(760) 321-1579
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 4CENSUS: 4DATE:
03/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Direct Support Person, Jaxon RuckerTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to cite for a case management deficiencies, on a visit regarding the health, safety, and welfare of residents in care. RIV RO, Community Care Licensing received an SIR on September 19, 2023 for Benson House #10, in which was reported, that an ex-staff member (S1) kissed a client and provided marijuana to resident 1 (R1). LPA met with the Direct Support Person, Jaxon Rucker and informed him of the purpose of the visit. LPA was informed that four (4) residents currently reside at this facility, with a capacity of four (4). There were two (2) staff on duty and two (2) residents were present at facility during the time of the visit. The LPA spoke to the Administrator, Erica Mata over the phone regarding the case management deficiency.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care.

There are two (2) deficiencies being cited, per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted, a copy of this report, the 809-D, an 811, and appeal rights were provided to the Direct Support Person, Jaxon Rucker.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2024
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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Document Has Been Signed on 03/06/2024 11:55 AM - It Cannot Be Edited


Created By: Kathleen Banrasavong On 03/04/2024 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENSON HOUSE, INC #10
FACILITY NUMBER: 336412351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
HSC
80065(a)

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80065
Personnel Requirements
a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall...to meet such needs.This requirement is not met as evidenced by:
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The Administrator, Erika Mata has agreed to provide to the LPA, an updated LIC 500 where the Administartor or House manager will do a Quality and Assurance check on the NOC shifts.
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in allowing S1, to work at the facility, and provided marijuana to R1, which poses an immediate health, safety or personal rights risk to person 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/06/2024 11:55 AM - It Cannot Be Edited


Created By: Kathleen Banrasavong On 03/04/2024 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENSON HOUSE, INC #10
FACILITY NUMBER: 336412351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2024
Section Cited
HSC
80065(a)

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80065
Personnel Requirements
a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall...to meet such needs.This requirement is not met as evidenced by:
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The Administrator, Erika Mata has agreed to provide to the LPA, all of the staff signature going over the house rules and regulation regarding personal rights and staff and resident appropriate behaviors.
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Based on observation, interview and record review, the Administrator did not comply with the section cited above in allowing S1, to work at the facility, and kissed R1, which poses an immediate health, safety or personal rights risk to person 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.
SUPERVISOR'S NAME:Jazmond D Harris
LICENSING EVALUATOR NAME:Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024


LIC809 (FAS) - (06/04)
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