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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366407339
Report Date: 12/15/2025
Date Signed: 12/15/2025 01:05:36 PM

Substantiated


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
12/10/2025 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251210112006
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: 4DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Antoinette IrvinTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff does not treat resident with respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above allegation. LPA Prieto met with Administrator Antoinette Irvin and explained the elements of the complaint.

Allegation #1 - LPA Prieto interviewed Administrator Irvin who states she was made aware of staff #1 (S1) speaking to resident #1 (R1) in a manner, without respect, violating R1's personal rights. This incident occurred in May 2025. Irvin states that the facility staff was subsequently provided in service training regarding the topic of "Rights of Person with Developmental Disability. Client's Rights and the denial of Rights Process."

LPA Prieto interviewed S2 and S3 who state that they where made of the incident that occurred in May of 2025, but state that the incident has reoccurred since. S1 was not available for interview as they work the NOC shift and works one day a week at the facility.
***continued on LIC 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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 3
Control Number 56-AS-20251210112006
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: 12/15/2025
NARRATIVE
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LPA Prieto interviewed R2 at the facility, at time of investigation and states that staff has not disrespect him. LPA Prieto interviewed R3 who stated that he has been treated with disrespect, but S1, since the incident in May of 2025. LPA Prieto interviewed R4 who states the S1 has treated and spoken to in a disrespectful manner. R4 states the incident originally occurred in May of 2025 and has subsequently occurred since.

Based on LPA observations, interviews which were conducted and records review, the preponderance of evidence standard has been met. Therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22) are being cited on the attached LIC 9099D. This report was signed by LPA Prieto and Administrator Irvin and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20251210112006
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
80072(a)(1)
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(a)Except for children’s residential facilities, each client shall have personal rights which include...:
(1)To be accorded dignity in his/her personal relationships with staff and other persons...this requirement is not met as evidenced by:
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The Licensee/Administrator agreed to conduct in-service training with staff on the regulation cited by POC due date.
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Staff and client interviews reveal staff #1, spoke to resident #3 and #4 in a manner that was disrespectful.
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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.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3