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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530051
Report Date: 02/22/2023
Date Signed: 03/27/2023 01:50:48 PM

Document Has Been Signed on 03/27/2023 01:50 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENEVOLENCE BOARD & CAREFACILITY NUMBER:
365530051
ADMINISTRATOR:GONZALES, AMANDAFACILITY TYPE:
740
ADDRESS:241 EAST CHAPARRAL STREETTELEPHONE:
(909) 341-5156
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 6DATE:
02/22/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amanda GonzalesTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Victoria Chitgian conducted an announced visit to the facility to conduct a pre-licensing inspection. LPA met with Amanda Gonzales.

Based on initial observations made by the LPA, the pre-licensing inspection is not able to be completed at this time due to lack of bulletin board with required postings, Staff member residing in the activity room inconsistent with the floor plan, and lack of night stand in bedroom #1. Submitted floor plan also has inaccuracy regarding shared and private resident rooms.

LPA and licensee will reschedule a pre licensing inspection once all corrections have been completed and all other elements of the pre-licensing checklist are complete.
COMP III was completed.
Pre-Licensing is incomplete. A follow up Pre-Licensure LIC 809 will be generated upon completion.

An exit interview was conducted where is report was discussed and provided to Amanda Gonzales.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Victoria Chitgian
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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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