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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530139
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:51:56 AM

Document Has Been Signed on 12/23/2024 11:51 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:BENCHMARK TRANSITIONSFACILITY NUMBER:
365530139
ADMINISTRATOR/
DIRECTOR:		CLARK, MICHELEFACILITY TYPE:
772
ADDRESS:10132 CAMULOS AVETELEPHONE:
(818) 209-5011
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY: 6CENSUS: 4DATE:
12/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Kyle Gonering, Primary TherapistTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/23/2024 at 9:40 AM Licensing Program Analyst (LPA) Eldin Serrano arrived at Benchmark Transitions Social Rehabilitation Facility to conduct a Case Management Visit. This Case Management Visit is in response to a report from Department of Health Services regarding three (3) beds in one bedroom. LPA was greeted by Primary Therapist Kyle Gonering at the door and granted entry. LPA introduced self and stated purpose of the visit.

Structure: Facility is a single-story home with four (4) bedrooms. Bedroom #4 is being used as the Therapist Office. The facility has two (2) bathrooms (one in hallway and one in bedroom #1). There is a living room, dining area, and kitchen area and the home has central heating and air conditioning system.

Bedrooms: Each resident bedroom will accommodate ambulatory only clients. The bedrooms were adequately furnished with bed, chair, and closets with adequate lighting. LPA observed that there is a bedroom that has three (3) beds in it that violates Title 22 CCR regulation 81087(e)(1). There were only two clients in bedroom #1 that LPA observed. The third bed is not occupied by any client. Citation will be issued.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured at 108.6 F.

Kitchen: There is an adequate supply of dishes, glasses, utensils, pots, and pans were observed. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable and non-perishable food items. There was adequate seating for meals. The knives/sharp instruments is locked in the kitchen.

Medications is locked in a secured metal grey cabinet in the staff office.

*** Continuation in LIC809C ***

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BENCHMARK TRANSITIONS
FACILITY NUMBER: 365530139
VISIT DATE: 12/23/2024
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Living/Family room: Furnished with safe and adequate seating. All items appear to be in good repair.

Linens and Hygiene Supplies: There is an adequate supply of linens and hygiene supplies.

Yards/Outside: There is a covered patio area for staff and clients with adequate furniture available for sitting. There were no bodies of water observed anywhere on the property.



Food Service: LPA Serrano observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Deficiency was cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, and Appeal Rights were discussed, and copies were provided to Primary Therapist Kyle Gonering.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2024 11:51 AM - It Cannot Be Edited


Created By: Eldin Serrano On 12/23/2024 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENCHMARK TRANSITIONS
FACILITY NUMBER: 365530139

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2024
Section Cited
CCR
81087(e)(1)

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81087 Buildings and Grounds
(e) Bedrooms must meet, at a minimum, the following requirements: (1) No more than two clients shall sleep in a bedroom unless the program justifies a group living arrangement of more than two persons to a room and such arrangement is approved in writing by the licensing agency.
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Licensee removed the extra bed from bedroom #1 at the time of the case management visit.
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above by not ensuring that no more than two clients can sleep in a bedroom unless the program justifies a group living arrangement which poses an immediate health, safety or personal rights risk to persons in care.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Eldin Serrano
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2024


LIC809 (FAS) - (06/04)
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