<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360908345
Report Date: 06/30/2022
Date Signed: 06/30/2022 11:25:38 AM

Document Has Been Signed on 06/30/2022 11:25 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:BENSON HOUSEFACILITY NUMBER:
360908345
ADMINISTRATOR:SHAWN COLETTAFACILITY TYPE:
735
ADDRESS:1941 S. BENSONTELEPHONE:
(909) 983-7884
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 9CENSUS: 5DATE:
06/30/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Shawn ColettaTIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melody Brown arrived unannounced at the facility 06/30/2022 at 11:15 AM for the purpose of a Plan of Correction (POC) visit. LPA Brown met with Administrator Shawn Coletta and LPA Brown explained the purpose of the visit.

On 06/17/2022 the facility was issued a deficiency on CCR 80044(a) Inspection Authority of the Licensing Agency with a plan of correction date on 06/24/2022. On 06/20/2022, Administrator Coletta informed LPA Brown that he had the key already to open the garage. Per Plan of Correction issued, the licensee stated to allow Community Care Licensing (CCLD) to access the garage by POC due date. During the visit, LPA Brown conducted a physical plant assessment of the plan of correction. LPA Brown was granted access to the garage and no issues observed. The garage was used as a storage. Licensee submitted the required Statement of Understanding to LPA Brown last 06/17/2022. LPA Brown has determined that the plan of correction has been met.

Facility will receive a Letter of Deficiency Citation Cleared for the deficiency cleared during inspection.

An exit interview was conducted where this report (LIC809) was discussed and provided to Administrator Shawn Coletta.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1