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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366407339
Report Date: 06/04/2025
Date Signed: 06/04/2025 12:50:27 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2025 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20250527100614
FACILITY NAME:BENSON HOUSE #5FACILITY NUMBER:
366407339
ADMINISTRATOR:ANTOINETTE IRVINFACILITY TYPE:
735
ADDRESS:6273 WALNUT AVENUETELEPHONE:
(909) 248-0843
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY:4CENSUS: 3DATE:
06/04/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Antoinette Irvin, AdministratorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
Staff did not follow doctor's orders
Staff did not ensure that resident received eyeglasses as prescribed
Staff mishandled resident's personal funds
Staff did not provide resident with nutritious meals
Staff did not provide resident with activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegations. LPA Prieto met with Administrator Irvin and explained the elements of the complaint.

Allegation #1 - Resident #1 (R1), in question, was not available for interview and longer resides in the home. LPA Prieto obtained resident's Medication Administration Record (MAR) log that reveals medications are being dispensed as prescribed.

Allegation #2 - LPA Prieto obtained doctor's orders relating to R1, stating that facility is to use fragrance free laundry detergent as R1 is diagnosed with a skin condition. LPA observed detergent at the home that is dye and fragrance free.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20250527100614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #5
FACILITY NUMBER: 366407339
VISIT DATE: 06/04/2025
NARRATIVE
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Allegation #3 - Facility administrator provided LPA with an invoice regarding R1's prescribed eyeglasses and it's cost.

Allegation #4 - LPA Prieto obtained a copy of R1's Record of Client's/Resident's Safeguarded Cash Resources form that reveal the resident's personal funds are handled properly. Resident's P & I records reveal that funds are accounted for and documented.

Allegation #5 - LPA inspection of food supplies shows that the facility has a sufficient amount of perishables and non perishables at the home. Interviews with staff #1 (S1) and S2 state the meals for resident's are of good quantity and quality.

Allegation #6 - Interviews with S1, S2 and S3 states that residents are taken to activities and eateries in the local area. LPA Prieto reviewed facility activities calendar that shows a variety of activities for resident's each month.

Based on the information obtained there is not enough evidence to support the allegations made in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Administrator Irvin and a copy was left at the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2