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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530051
Report Date: 05/30/2025
Date Signed: 05/30/2025 09:59:50 AM

Document Has Been Signed on 05/30/2025 09:59 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENEVOLENCE BOARD & CAREFACILITY NUMBER:
365530051
ADMINISTRATOR/
DIRECTOR:		GONZALES, AMANDAFACILITY TYPE:
740
ADDRESS:241 EAST CHAPARRAL STREETTELEPHONE:
(909) 341-5156
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 0DATE:
05/30/2025
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Amanda Gonzales, LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:05 AM
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On 05/30/2025 at 9:16 AM, Licensing Program Analysts (LPA) LaVette Farlow conducted an announced visit to confirm that all of the residents have been relocated in anticipation for the facility's relocation. LPA Farlow were granted entrance by Amanda Gonzales, Licensee.

On 05/30/2025 at 9:20 AM, LPA Farlow conducted a tour of the home and observed that there are no more residents living in the facility. The licensee is initiating this closure and relocating to a new facility named Benevolence Board & Care II. LPA inspected the entire facility which included the 5 bedrooms, 2 bathrooms, living room, dining area, kitchen, office and the backyard. There were no residents present, and there were no belongings of residents in the facility. Licensee Amanda Gonzales stated that the reason for the relocation is due to the landlord not wanting to renew the lease agreement.



Licensee Amanda Gonzales submitted the following during the closure plan.

1. Letters to residents indicating the closure, and letter to Community Care Licensing Division (CCLD).
2. Names of the five (5) residents (resident roster) and there location at Benevolence Board & Care II. Also, one (1) resident new location address and contact person.
3. Licensee surrendered the Hospice Waiver Approval letter from CCLD.

Amanda Gonzales surrendered the original license to LPA Farlow.

The effective date of closure will be 05/30/2025.

An exit interview was conducted, where this report, LIC809 was discussed with and provided to Amanda Gonzales.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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