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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602277
Report Date: 09/09/2021
Date Signed: 09/09/2021 03:04:39 PM

Document Has Been Signed on 09/09/2021 03:04 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:BENCY'S RANCHFACILITY NUMBER:
374602277
ADMINISTRATOR:MARILYN B JIMENEZFACILITY TYPE:
735
ADDRESS:731 W 16TH AVETELEPHONE:
7607438179
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 5DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff, Roland JavierTIME COMPLETED:
01:21 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA was greeted and allowed entry into the facility by staff, Rosa Flores. LPA discussed the purpose of the visit with Staff, Roland Javier.

During today's visit, LPA briefly toured the visit, requested records, and interviewed staff. On 09/08/21, Community Care Licensing received a self reported death report, involving client #1 (C1). The report stated C1 passed away on 09/06/21, due to a medical condition. No deficiencies were issued today.

An exit interview was conducted with staff, Roland Javier and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the staff via electronic mail. An electronic read receipt confirmation was requested to be sent by the staff upon receipt of the documents.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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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