360908345-10-31-2024-56-AS-EMAN-DBKQWG-20241202113154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 360908345
Report Date: 10/31/2024
Date Signed: 10/31/2024 11:55:43 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 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
10/29/2024 and conducted by Evaluator Raquel Hernandez

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20241029180752

FACILITY NAME:	BENSON HOUSE		FACILITY NUMBER:	360908345
ADMINISTRATOR:	SHAWN COLETTA		FACILITY TYPE:	735
ADDRESS:	1941 S. BENSON		TELEPHONE:	(909) 983-7884
CITY:	ONTARIO	STATE: CA	ZIP CODE:	91762
CAPACITY:	9	CENSUS: 5	DATE:	10/31/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Shawn Coletta		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Licensee is not ensuring that client(s) are provided with activities while in care.
Licensee is not ensuring that the facility is kept free of potential hazard(s) to clients in care.
Staff are not providing adequate supervision to client in care resulting in client sustaining multiple falls.
Staff are not ensuring that client's toileting needs are met while in care.
Staff are not ensuring that clients are attending their doctors' appointments while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Raquel Hernandez and Mary Rico conducted an unannounced visit to deliver findings on the allegation listed above. LPAs met with Administrator Shawn Coletta and explained the purpose of the visit. The investigation consisted of staff interviews, client interviews and facility tour.

For the allegation, Licensee is not ensuring that resident(s) are provided with activities while in care.

LPA Hernandez conducted two (2) client interviews and four (4) staff interviews. During client interviews 2 out of the 2 clients stated they are provided with activities while in care. During staff interview 4 out of the 4 staff also stated that clients have activities to participate in. LPAs Hernandez and Rico observed updated activity calendar located in the living room.

For the allegation, Licensee is not ensuring that the facility is kept free of potential hazard(s) to clients in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20241029180752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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	FACILITY NUMBER: 360908345
	VISIT DATE: 10/31/2024

NARRATIVE

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LPAs Hernandez and Rico observed updated activity calendar located in the living room.

Based on the evidence gathered during today’s investigation, the allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Shawn Coletta.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 56-AS-20241029180752

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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	FACILITY NUMBER: 360908345
	VISIT DATE: 10/31/2024

NARRATIVE

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During facility tour, LPAs Hernandez and Rico observed no potential hazards to clients in care. During interviews, 4 out of the 4 staff stated that potential hazardous items are kept in a locked cabinet in office room.

For the allegation, Staff are not providing adequate supervision to client in care resulting in client sustaining multiple falls.

During staff interviews, 4 out of the 4 staff stated they provide adequate supervision. 1 out of the 4 staff stated they have witnessed C1 fall, but staff have followed the proper protocols. 2 out of the 2 clients stated that staff provide adequate care and supervision and receive medical attention.

For the allegation, Staff are not ensuring that resident's toileting needs are met while in care.

During interview, 4 out of the 4 staff stated they do assist clients when they need help and most of them are able to go alone beside's C1. LPAs observed C1's care notes on toileting and when assistance is needed.

For the allegation, Staff are not ensuring that residents are attending their doctors' appointments while in care.

During interview and record review, LPAs Hernandez and Rico observed C1 and C2 monthly/weekly doctor appointments. During interviews, 4 out of the 4 staff stated they do take clients to their doctors appointments when they are scheduled.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Shawn Coletta.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC9099 (FAS) - (06/04)

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