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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366407339
Report Date: 10/28/2021
Date Signed: 10/28/2021 01:22:55 PM

Document Has Been Signed on 10/28/2021 01:22 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 #5FACILITY NUMBER:
366407339
ADMINISTRATOR:ANTOINETTE IRVINFACILITY TYPE:
735
ADDRESS:6273 WALNUT AVENUETELEPHONE:
(909) 248-0843
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 3DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Antoinette Irvin - AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility. The purpose of today's visit is to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Bueno met with Administrator Antoinette Irvin. Irvin confirmed that the facility has no active cases and/or suspected exposure of Covid-19.

During the inspection, LPA Bueno and Administrator Irvin conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA observed that the facility had several COVID-19 postings throughout the facility. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA Bueno also observed that all staff members are properly fitted with face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the client presents any COVID-19 symptoms.

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy of this report was also provided to Irvin at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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