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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 360908345
Report Date: 04/07/2025
Date Signed: 04/07/2025 03:31:27 PM

Substantiated


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
02/13/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250213141524
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:
04/07/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:House Manager Lisa BuyersTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff mishandled a client's medications
Staff yelled at a client while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegationslisted above. LPA met with House Manager Lisa Buyers and explained the purpose of the visit. The investigation consisted of staff and client interviews and request of documentation.

LPA Hernandez conducted (5) client interviews. 4 out of the 5 clients stated Staff #1 (S1) has yelled at them. Additionally, LPA Hernandez conducted (5) staff interviews. 5 out of the 5 staff stated they have not witnessed any facility staff yell at the clients in care.

LPA Hernandez reviewed Medicine Administration Record (MAR) for Client #4 (C4) where it was labeled as a home visit. LPA Hernandez spoke with Administrator Shawn Coletta pertaining to Client #4 (C4) medication that was not given to them on a home visit. LPA Hernandez observed client was not given medication from 12/22/2024-12/24/2024.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
02/13/2025 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250213141524

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: DATE:
04/07/2025
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:House Manager Lisa BuyersTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Staff demonstrated inappropriate form of discipline
Staff enforces a client to clean the facility
Staff made inappropriate comments towards a client
Staff did not provide timely medical information to an authorized representative
INVESTIGATION FINDINGS:
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3
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5
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7
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10
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13
Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Administrator Shawn Coletta and explained the purpose of the visit. The investigation consisted of staff and client interviews and request of documentation.

For the allegation, Staff made inappropriateorm of discipline

LPA Hernandez conducted (5) client interviews. 5 out of the 5 clients stated facility staff have not demonstrated an inappropriate form of discipline. LPA Hernandez conducted (5) staff interviews. 5 out of the 5 staff stated they do not demonstrate inappropriate forms of discipline towards clients in care.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20250213141524
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: 04/07/2025
NARRATIVE
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For the allegation, Staff enforces a client to clean the facility.

LPA Hernandez conducted (5) client interviews. 5 out of the 5 clients stated the facility staff that does not enforce them to clean the facility. LPA Hernandez conducted (5) staff interviews. 5 out of the 5 staff stated they do not enforce clients to clean the facility.

For the allegation, Staff made inappropriate comments towards a client.

LPA Hernandez conducted (5) client interviews. 4 out of the 5 clients stated facility staff do not make inappropriate comments towards them nor have they witnessed facility staff make inappropriate comments to other clients in care. LPA Hernandez conducted (5) staff interviews. 5 out of the 5 staff stated they do not make inappropriate comments towards clients in care.

For the allegation, Staff did not provide timely medical information to an authorized representative.

LPA Hernandez spoke with Administrator Shawn Colletta pertaining to medical information for Client #4 (C4). Administrator Shawn Colletta stated they did send over medical information to authorized representative.

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 pertaining to these allegations 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: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20250213141524
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: 04/07/2025
NARRATIVE
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Based on the evidence gathered during today’s investigation, the allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegation are valid because the preponderance of evidence the standard has been met.

During today’s visit, two deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and LIC9099D was discussed and provided to Administrator Shawn Colletta along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20250213141524
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2025
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a)..each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Licensee stated to submit staff training on regulation stated to LPA Hernandez by Plan of Correction (POC) due date.
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Based on observation, the licensee did not comply with the section cited above by not ensuring Staff #5 (S5) treated clients in care with dignity and respect, which poses an immediate health, safety and personal rights risk to those in care.
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Type A
04/08/2025
Section Cited
CCR
80075(5)(B)
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(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication... (B) Once ordered by the physician the medication is given according to the physician's directions.
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Licensee stated to submit staff training on regulation stated to LPA Hernandez by POC due date.
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Based on observation and record review, licensee did not comply with the section cited above by not ensuring Client #4 (C4) medication was given according to medication label, which poses an immediate health, safety and personal rights risk to those in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5