<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602277
Report Date: 10/27/2021
Date Signed: 10/27/2021 04:13:38 PM

Document Has Been Signed on 10/27/2021 04:13 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:
(760) 743-8179
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 5DATE:
10/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Aministrator, Melissa Jimenez SumibcayTIME COMPLETED:
11:20 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Manager (LPM), Simon Jacob and Licensing Program Analyst (LPA), Kayla Hilario conducted an unannounced annual required licensing inspection. LPM and LPA were allowed entry into the facility by Staff, Rosa Flores and met with Administrator, Melissa Jimenez Sumibcay and Staff, Roland Javier. LPM and LPA stated the purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

During today’s visit, LPM and LPA toured the facility and reviewed the facility’s Plan for Epidemic Outbreak Specific to COVID-19 Mitigation Plan Report (LIC 808) with Administrator Jimenez including the following sections: Person in Care; Staff; Visitors; Residents; Facilities without COVID-19; and Facility has Plans for Infection Control and Physical Distancing. LPM and LPA assessed the strategies that the facility is employing for the prevention, containment and mitigation of COVID-19, implementation of infection control guidance, staff retention and essential health and safety.

LPM and LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.

No deficiencies were observed during today’s visit. An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Administrator via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents..
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1