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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402747
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:40:56 PM

Document Has Been Signed on 02/23/2022 01:40 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENSON HOUSE, INC. #3FACILITY NUMBER:
366402747
ADMINISTRATOR:JACK HINCHMANFACILITY TYPE:
735
ADDRESS:12417 BENSON AVE.TELEPHONE:
(909) 591-7464
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 4DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Manager Antoinette Irvin TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility for an annual inspection. LPA met with Manager Antoinette Irvin and

LPA observed that the facility has a mitigation plan to mitigate the spread of COVID-19 in the facility. There is one central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the home inside and there are charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The hallways were free of obstruction. The client rooms had the required furniture and sufficient lighting.

LPA measured the hot water temperature in the main bathroom that measured 105.2 degrees F. There were handrails in all bathrooms to accommodate the needs for bathing and showers have textured non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BENSON HOUSE, INC. #3
FACILITY NUMBER: 366402747
VISIT DATE: 02/23/2022
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Cleaning supplies were locked in a cabinet in the garage and medications were locked in a Closet at front door entry.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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