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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412351
Report Date: 03/11/2022
Date Signed: 03/11/2022 01:13:08 PM

Document Has Been Signed on 03/11/2022 01:13 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
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:
03/11/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Breanna BridgesTIME COMPLETED:
01:15 PM
NARRATIVE
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On 3/11/22, Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of conducting a health and safety check on the residents of the facility. LPAs Colvin and Mixon met with Administrators Breanna Bridges and Erica Mata and discussed the purpose of today's visit.

LPAs discussed recent Special Incident Reports (SIRs) with Administrator as well as the plans developed by the facility to ensure continued health and safety of all residents. Resident 1 (R1) has had two recent incidents of drinking hand sanitizer and subsequently needing medical attention. In the facility's plan for action, they stated that staff will have line of sight supervision on R1 at all times that R1 is not in their bedroom or bathroom, and otherwise conduct hourly checks. The facility additionally stated that all hand sanitizer would be removed from the facility to ensure resident safety.

During today's unannounced inspection, LPA Colvin toured the facility and examined all unlocked areas for potential hazardous chemicals. LPA Colvin observed all but one room to be free of chemicals. LPA Colvin was able to enter the staff office, as it was unlocked, and on the bookshelf in the office, LPA Colvin observed a large (over 20 ounces) bottle of hand sanitizer. LPA Colvin pointed the item out to staff along with the fact that the room was not locked when LPAs arrived and LPA Colvin was able to access the hand sanitizer without staff assistance. Additionally, the only staff (S1) present at the time of LPAs arrival was not actively in the staff office, and was cleaning the kitchen area, leaving the unlocked room unsupervised. This is an immediate health and safety risk to R1 as the second incident of R1 drinking hand sanitizer it is believed that R1 obtained it from a locked staff area (staff bathroom). Deficiency cited. LPA Colvin additionally expressed her concern of R1's access to hand sanitizer (and subsequent ingestion of it), as it is outlined in R1's placement paperwork (IPP) that R1 has a history of substance abuse, including ingestion of hand sanitizer.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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 03/11/2022 01:13 PM - It Cannot Be Edited


Created By: Crystal Colvin On 03/11/2022 at 12:52 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: 03/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/12/2022
Section Cited
CCR
80087(g)

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Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Staff have removed the hand sanitizer during today's inspection. Staff will conduct an additional sweep of the facility to confirm that no other hand sanitizer is on site (per faciltiy's plan of action) and that all areas that are locked are kept locked. Licensee may self certify once complete.
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Based on observation, the Licensee did not comply with the above regulation with at least one room of the facility. LPA Colvin observed hand sanitizer to be unlocked and accessible in the staff office. This is an immediate health and safety risk to residents in care.
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Type B
03/18/2022
Section Cited
CCR80036(a)

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LICENSING FEES: (a) An applicant or a licensee shall be charged fees as specified in Health and safety Code Section 1523.1. This requirement was not met as evidenced by:
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Licensee agrees to pay all fees due. Licensee may self-certify to LPA Colvin once complete. Plan of Correction date of 3/18/22.
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Based on record review, the Licensee did not comply with the above regulation with the annual fees. LPA Colvin observed that the annual licensing fees for 2021 have not been paid, and that the facility has accrued a late fee. This is a potential safety risk to residents in care, as the license can be revoked.
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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:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022


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
RIVERSIDE, CA 92507
FACILITY NAME: BENSON HOUSE, INC #10
FACILITY NUMBER: 336412351
VISIT DATE: 03/11/2022
NARRATIVE
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Additionally, in review of the facility's file prior to coming out to the facility, LPA Colvin observed that the Licensee has failed to pay their annual licensing fees, along with the subsequent late fee from 2021. The Licensee currently owes $681.00. Deficiency cited.

An exit interview was conducted with Administrators Breanna Bridges and Erica Mata, and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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