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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360908345
Report Date: 07/10/2024
Date Signed: 07/10/2024 11:47:20 AM

Document Has Been Signed on 07/10/2024 11:47 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/
DIRECTOR:		SHAWN COLETTAFACILITY TYPE:
735
ADDRESS:1941 S. BENSONTELEPHONE:
(909) 983-7884
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 9CENSUS: 5DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Shawn Coletta- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Bernadette Allen made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection. LPA met with Valerie Smith assistant Administrator to Shawn Coletta. The facility is an eight (8) bedroom, four (4), bathroom home and, with a kitchen/dining area, living room and garage. The facility is an Adult Residential Facility (ARF) level 4I designated home vendor by Inland Regional Center. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

LPA observed sufficient furniture and lighting throughout the facility. The hot water temperature tested within regulation at 124 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area.

Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients in care. All sharps are locked in med-cart in locked office. There was a designated office for client/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for clients in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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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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
, CA 92507
FACILITY NAME: BENSON HOUSE
FACILITY NUMBER: 360908345
VISIT DATE: 07/10/2024
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Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed two (2) client medications and P&I were reviewed. LPA also reviewed one (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

Based on the observations made 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 (LIC809) was discussed and provided to Facility Administration Shawn Coletta at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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