336412353-10-19-2023-18-AS-JARA-CWRW5T-20231019165940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336412353
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:59:46 PM

Document Has Been Signed on 10/19/2023 04:59 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BENSON HOUSE, INC #12		FACILITY NUMBER:	336412353
ADMINISTRATOR:	AURORA ARZATE		FACILITY TYPE:	735
ADDRESS:	44840 SAN BENITO		TELEPHONE:	(760) 346-5409
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92260
CAPACITY: 6		CENSUS: 4	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator, Erica Mata		TIME COMPLETED:	05:10 PM

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On 10/19/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Erica Mata, who was informed of the purpose of the visit. At the time of the visit there was (3) staff and (1) resident present.

The facility is a one story home with attached garage. No firearms or pools are present at the facility. The home has (4) bedrooms and (3) bathrooms. The clients served are adults ages 18 to 59 years of age. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train staff on infection control guidelines. Technical advisory note was documented for staff to have infection control plan at the facility for licensing review.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide were operational, and the hot water temperature was recorded at 105.2F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENSON HOUSE, INC #12	FACILITY NUMBER: 336412353
	VISIT DATE: 10/19/2023

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Record Review and Resident/Staff Files: LPA reviewed staff files and training. Staff have criminal clearance, (4) staff members were not on the guardian roster however the staff was able to prove they possessed a cleared background and transfer request. Staff have updated training along with CPR/First Aid Certification. The administrator has proof of a processing administrator certificate with the department. Resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in kitchen pantry. LPA reviewed resident medications, all of which were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 8/13/2023. LPA observed emergency exits and emergency supplies.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was reviewed and provided to Administrator, Erica Mata.

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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