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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 360908345
Report Date: 06/17/2022
Date Signed: 06/17/2022 12:08:38 PM

Document Has Been Signed on 06/17/2022 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:SHAWN COLETTAFACILITY TYPE:
735
ADDRESS:1941 S. BENSONTELEPHONE:
(909) 983-7884
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 9CENSUS: 5DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Shawn CollettaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 06/17/2022 at 09:15 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Administrator Shawn Coletta and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Administrator Coletta reported that they have five (4) clients at the facility. Below is a summary of what was observed:

Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Administrator Coletta. Per documents review, Mitigation Plan was submitted 07/16/2021.

LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing, and signs have been posted at facility entrance with updates to visitor policy to notify of policies and procedures necessary to protect residents from infection during pandemic. LPA Brown toured the facility's and all rooms and bathrooms have hand soap and paper towels. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply and the facility has sufficient supply of PPE. LPA Brown went over the various recommended training for facility staff with Administrator Coletta in relation to COVID-19 and Administrator Coletta informed LPA Brown that all staff are trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.

LPA Brown inquired as to if staff have been fit tested for N95 masks, and Administrator Coletta informed LPA Brown that all staff have not been fit tested at this time. LPA Brown will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks.


**** Continuation in LIC809C ****
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: 06/17/2022
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LPA Brown will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results.

LPA Brown observed all clients been vaccinated and boosted and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and their clients, when and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also has a plan in place to monitor their clients regularly for any changes in condition and to subsequently notify the clients physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

During the tour of the facility, LPA Brown was denied access to the facility's garage by Administrator Coletta as Administrator Coletta reported that the garage opener cannot be found. LPA Brown informed Administrator Coletta that citation will be issued as this pose a potential risk to clients in care.

In addition, during the visit, LPA Brown requested staff vaccination records and on 06/17/2022 at 10:30 AM, LPA Brown observed Staff 3, Staff 7 and Staff 8, Staff 10, Staff 15, Staff 16, Staff 17, Staff 18 have first, second and booster vaccination. However, Staff 1 have no Booster exemption. Also, Staff 2, Staff 6, Staff 19 have dose 1 and dose 2 but no booster vaccination record or exemption. Moreover, Staff 4, Staff 5, Staff 9, Staff 11, Staff 12, Staff 13, Staff 14, Staff 20 and Staff 21 do not have a dose 1, dose 2 and booster vaccination record/exemption at the facility. LPA Brown will be issuing a deficiency for this item as this pose potential risk to clients in care.

An exit interview was conducted with Administrator Shawn Coletta and a copy of this report (LIC809), LIC 809D, LIC9102 TA Advisory Notes and Appeal Rights were discussed and provided.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2022 12:08 PM - It Cannot Be Edited


Created By: Melody Brown On 06/17/2022 at 11:17 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BENSON HOUSE
FACILITY NUMBER: 360908345

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80044(a)

80044 Inspection Authority of the Licensing Agency (a) The licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5, 1533, 1534, 1538 and 1538.7.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by deniying LPA Brown access to the garage during the tour of the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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Licensee stated to allow Community Care Licensing Department (CCLD) access to the garage by POC due date.
Licensee stated to submit Statement of Understanding to California Code of Regulations (CCR) 80044(a) to LPA Brown by POC due date.
Type B
Section Cited
HSC
121125,120140,120275


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the LIcensee did not comply with the section cited above by not ensuring the personal rights of persons in care to live in a safe, healthy, comfortable home failed to comply with reporting and personnel requirements and engaged in conduct inimical to the health, welfare and safety of persons in care in that the LIcensee did not verify workers vaccination, booster or exemption status or unvaccinated worker's test result as applicable by maintaining a record as required by State Public Officer Order of December 22, 2021 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2022
Plan of Correction
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Licensee stated to submit proof of vaccination/booster/exemption records of Staff 1, Staff 2, Staff 6, Staff 9, Staff 11, Staff 12, Staff 13, Staff 14, Staff 19, Staff 20 and Staff 21 to LPA Brown by POC due date. Also, LIcensee stated to update staff vaccination record at the facility by POC due date..
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022


LIC809 (FAS) - (06/04)
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