365530051-2-27-2024-56-AS-ACON-D2UPV9-20240227103846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530051
Report Date: 02/27/2024
Date Signed: 02/27/2024 10:39:00 AM

Document Has Been Signed on 02/27/2024 10:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BENEVOLENCE BOARD & CARE		FACILITY NUMBER:	365530051
ADMINISTRATOR:	GONZALES, AMANDA		FACILITY TYPE:	740
ADDRESS:	241 EAST CHAPARRAL STREET		TELEPHONE:	(909) 341-5156
CITY:	RIALTO	STATE: CA	ZIP CODE:	92376
CAPACITY:	6	CENSUS:	DATE:	02/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Agung Prabowo, Caregiver & Amanda Gonzales, Administrator		TIME COMPLETED:	10:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Benevolence Board and Care facility unannounced to conduct the Annual Inspection. LPA was greeted by staff member, Agung. LPA introduced self and stated purpose of the visit. LPA was granted entry, while staff contacted Administrator, Amanda Gonzales. LPA spoke with Administrator over the phone who agreed to meet with LPA. Administrator arrived later during the visit. The facility has 5 bedrooms, 2 bathrooms, kitchen, dining area, living room, attached garage, and backyard. The facility maintains a partnership with Innovage Healthcare. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating at the capacity approved by Community Care Licensing (CCL). Pathways were observed to be free of obstruction. The facility observed in comfortable temperature. LPA inspected resident bedrooms and found that each room included required furniture such as: mattresses, night stands, adequate storage and sufficient lighting. LPA inspected resident bathrooms; each bathroom was equipped with handrails, medical durable equipment and non-slip grip materials for safety purposes. Bathrooms were observed to clean, appliances functional and included adequate amounts of hand hygiene and paper supplies. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted on a regular basis. Last fire/disaster drill conducted August 2023. Fire Extinguisher observed in the facility Dining Room; last inspected October 2023. Cleaning supplies, toxins, sharps, and other dangerous items were observed secure inaccessible to residents in care. Medications were secure and inaccessible to residents. The facility also maintains a secure refrigerator for medications. Emergency and first aid kits were observed and readily available for residents in care. Food Service: The facility maintains well stocked a pantry of dry good and non-perishable food items all in good standing. Inside the kitchen LPA observed dishes, cups, and utensils were observed in proper storage and in adequate amounts. Non-perishable and perishable food supply is sufficient for number of residents in care.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 & CARE	FACILITY NUMBER: 365530051
	VISIT DATE: 02/27/2024

NARRATIVE

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Staff report that the facility maintains a weekly food menu in rotation; for breakfast, lunch, dinner and snacks. Facility offers its residents a variety of food items. Emergency food and water supply were also observed.

Signs/Posters: LPA observed posters throughout the facility. Posters observed: LET-US-KNOW, Facility License, Resident Rights, Mandated Reports, Resident Council, Theft and Loss Infection Control Long Term Care Ombudsman and Oxygen Use.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week; as there are staff members who reside on facility property.

Record Review: LPA reviewed resident files for Admissions Agreements, Updated Physician's Reports, Need and Services and CPR/First Aid. Two resident files contained Physician Reports which were not current. LPA reviewed staff files for First Aid/CPR Certification, Criminal Record Clearance, Training, and health screenings. LPA found that staff records included all documentation per regulation.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Based on observations, interviews and record reviews, 1 deficiency will be cited per Title 22, California Code of Regulations. An exit interview was conducted where this report was reviewed, discussed then provided to Facility Administrator.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/27/2024 10:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 & CARE	FACILITY NUMBER: 365530051
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews the licensee did not comply with the section cited above by not ensuring all residents files contained an update (current) Physician's Report which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Administrator agrees to assist the residents with making and keeping a doctor appointment to obatin a current/up to date medical assessment by way of a LIC602 - Physician's Report. Administrator agrees this task can be comepleted with verification submitted to the Community Care Licensing Office within the next 30 business days.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC809 (FAS) - (06/04)

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