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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 12:08:56 PM

Document Has Been Signed on 07/10/2024 12:08 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
, 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:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Shawn Coletta- Administrator TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPA) Bernadette Allen conducted an unannounced visit to the facility to conduct a case management visit and follow up on an adult client death. LPA Allen met with Shawn Coletta- Administrator who was informed of the purpose of the visit.

This case management visit consisted of collecting pertinent documentation and conducting staff interviews in regard to the death of Client #1 (C1). LPA Allen interviewed Staff #1 (S1) and Staff #2 (S2) for further information in regard to the death of (C1) and the events that led up to (C1's) death.

(S1) stated that there is no official death certificate or cause of death at this time. LPA Allen has advised the administrator Shawn Coletta to send a copy of the death certificate to Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

An exit interview was conducted where this report was discussed with Shawn Coletta and a copy was provided 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
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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