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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530139
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:27:12 PM

Document Has Been Signed on 01/18/2024 03:27 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:BENCHMARK TRANSITIONSFACILITY NUMBER:
365530139
ADMINISTRATOR:CLARK, MICHELEFACILITY TYPE:
772
ADDRESS:10132 CAMULOS AVETELEPHONE:
(818) 209-5011
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Tom McNulty, LicenseeTIME COMPLETED:
03:30 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at Benchmark Transitions announced visit to conduct the Pre-Licensing Inspection for a Social Rehabilitation Facility. LPA met with Wendy Galvan, Compliance Specialist, Tom McNulty, Licensee, Eddie Alvo, Clinical Director, Jazmin Galvan, Compliance Specialist, Darren Longnecker, Director of I.T. and Barbara Kimberling, Program Director. LPA introduced self and stated purpose of the visit. LPA was provided a space to work, then accompanied by staff on a tour of the property.

Application: The application is for a Social Rehabilitation Facility. Fire clearance has been granted for six (6) ambulatory adult residents. Fire clearance inspection was approved on 7/5/23.

Buildings and Grounds: The property is a residential home is composed of four, (4) Bedrooms, two, (2) Bathrooms, Living Room, Dining Room, Staff Office, Kitchen, Laundry Room, Backyard and attached Garage. Interior pathways were free of clutter and unobstructed. Fire Alarms, Smoke Alarms and Carbon Monoxide Alarms were tested, and found operational during the tour. Fire Extinguishers were located throughout the facility. Each fire extinguisher was observed fully charged and last inspected January 2024. The building is also equipped with an operable fire sprinkler system. The backyard provides ample space for activities; unobstructed pathways, shaded seating, timed lighting and a designated smoking area. There are no pools or bodies of water located on premises. Licensee and staff report there are no weapons or ammunition kept on the property. LPA observed that lighting was provided by various lamps and nightlights in and around the building.

Resident Rooms - LPA observed 4 resident rooms. Each room was equipped with required furniture such as mattresses with appropriate linens, sufficient lighting, seating, night stands, intact windows/screens and adequate storage space. Each resident room also included hygiene supplies and extra linens for each potential resident.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BENCHMARK TRANSITIONS
FACILITY NUMBER: 365530139
VISIT DATE: 01/18/2024
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Bathrooms - LPA observed two bathrooms. One bathroom attached to a resident rooms. Each bathroom included adequate amounts of paper supplies, hand hygiene supplies, waste receptacles, lighting, and non-slip grip materials.

Staff Office - During the tour of the staff office, LPA observed, a securable space for resident medications, a secure refrigerator for medications and secure areas for facility, staff and resident files. The facility maintains an internet connection and working landline phone for its residents. LPA also observed the facility's first aid kit and manual.

Kitchen - LPA observed adequate amounts of utensils, dishware and sufficient storage space. Sharp objects will be kept in a secure drawer. Staff report no chemicals will be maintained in the kitchen area. LPA noted a posted food menu and functional appliances. The water temperature was tested in the kitchen and measured at 110 degrees Fahrenheit within regulatory expectations.


Laundry Room & Garage - Laundry room accessible by secure door. Inside laundry room held operable washer and dryer. As well as secure spaces for laundry detergent and supplies. LPA observed the garage is also accessible by a secure door. Emergency water and disaster supplies were located inside.


Forms: The following forms were observed posted throughout the facility: Emergency Disaster Plan (LIC 610D), Facility Sketch and Evacuation Plan, Resident/Personal Rights, Labor laws, House Rules, Theft and Loss Policy and the Licensing Complaint Poster.

There were no concerns noted during the inspection. LPA will inform the Centralized Applications Bureau the home is ready to be licensed. An exit interview was conducted. This report was reviewed, discussed then provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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