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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881063
Report Date: 02/23/2022
Date Signed: 02/24/2022 07:54:54 AM

Document Has Been Signed on 02/24/2022 07:54 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
RIVERSIDE, CA 92507
FACILITY NAME:BENNETT ADULT RESIDENTIALFACILITY NUMBER:
361881063
ADMINISTRATOR:CHAVEZ, JOANNAFACILITY TYPE:
735
ADDRESS:6351 SYRACUSE ST.TELEPHONE:
(909) 497-1990
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 0DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Joann TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility for an annual inspection. LPA met with Administrator Joanna Chavez.

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. There is one central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the home inside and there are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The hallways were free of obstruction. The client rooms had the required furniture and sufficient lighting.

LPA measured the hot water temperature in the main bathroom that measured at 107.2 degrees F. There were handrails in all bathrooms to accommodate the needs for bathing and showers have non-slip mats. The facility had a supply of additional linen and extra hygiene items for the clients.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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
RIVERSIDE, CA 92507
FACILITY NAME: BENNETT ADULT RESIDENTIAL
FACILITY NUMBER: 361881063
VISIT DATE: 02/23/2022
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Cleaning supplies were locked in a closet near front door of the home. The medication will be stored in a locked cabinet in the dining area.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.

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

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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