366403589-9-25-2024-56-AS-JPRO-D8CPCG-20240821111154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366403589
Report Date: 08/21/2024
Date Signed: 09/25/2024 03:54:22 PM

Document Has Been Signed on 09/25/2024 03:54 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
, CA 92507

FACILITY NAME:	BENSON HOUSE, INC. #4		FACILITY NUMBER:	366403589
ADMINISTRATOR:	JACK HINCHMAN		FACILITY TYPE:	735
ADDRESS:	6220 WALNUT AVENUE		TELEPHONE:	(909) 464-9305
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY:	4	CENSUS: 4	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Repinya Leonard Isaac, Administrator		TIME COMPLETED:	11:20 AM

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Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced required 1 year visit to the facility. LPA met with Repinya Leonard Isaac, Administrator and discussed the purpose of the visit.

The facility is an Adult Residential Facility (ARF), license capacity of four (4) with a current census of (4) . All clients are ambulatory. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

LPA inspected the facility inside and out. Indoor and outdoor passageways were kept free of obstruction. Facility living room, dining room, family room and outdoor patio furniture is in good repair and sufficient for clients in care. The facility is maintained at a comfortable temperature of 76 degrees F. Laundry equipment and telephone service is in working condition. Facility has no outdoor bodies of water. Facility has a covered patio and self-latching gates.

The facility has sufficient indoor and outdoor areas for planned activities. Activities include arts and crafts, board games, day program participation, and community outings.

LPA inspected the kitchen. Facility has sufficient non-perishable and perishable food for number of clients in care. Facility food is stored in a safe and healthful manner. Facility has a weekly menu posted in the kitchen area. Facility has sufficient cups, plates and utensils for client use. Kitchen hot water temperature tested within regulation at 109.4 degrees F. Sharps, disinfectants, and chemicals are kept locked and inaccessible to clients in care.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BENSON HOUSE, INC. #4	FACILITY NUMBER: 366403589
	VISIT DATE: 08/21/2024

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LPA inspected client bedrooms. Bedrooms are equipped clean mattresses, nightstands, chairs and dressers. Bedrooms have sufficient linen and lighting.

LPA inspected client bathrooms. Client bathrooms are equipped with handrails. The hot water temperature tested within regulation at 110 degrees F. Bathrooms were in a safe and sanitary operating condition.

The facility is equipped with operating carbon monoxide alarms and fully charged fire extinguisher. A Disaster Drill was conducted on 7/6/24. Facility has posted in a common area the facility sketch, personal rights, disaster plan and emergency numbers. Facility has complete first aid kits and sufficient emergency supplies. Extra linen and towels were stored in hallway cabinet. Facility has sufficient personal hygiene products for clients in care.

LPA observed client medications are kept in a safe and locked cabinet inaccessible to clients in care. Medications were administered as prescribed.

LPA reviewed (2) client files for admission agreements, personal rights statements, Individual Program Plan (IPPs), client developmental assessments, and updated physician reports, all had the required documentation. LPA reviewed (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings, all had the required documentation.

Overall, the facility is clean, in good repair, and operating in safe conditions for the well-being of clients in care. No deficiencies were cited during today's visit.

An exit interview was conducted, where this report was discussed and a copy was provided to Repinya Leonard Isaac at the conclusion of the visit

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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