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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602277
Report Date: 12/23/2022
Date Signed: 12/23/2022 02:34:09 PM

Document Has Been Signed on 12/23/2022 02:34 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: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: 4DATE:
12/23/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Marilyn B Jimenez, AdministratorTIME COMPLETED:
02:45 PM
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A Case Management visit is made today by LPA Yolanda Delgado to follow up on a Death Report regarding the death of client #1 on 12/21/2022. LPA Yolanda Delgado met with Administrator Marilyn Jimenez and a request was made to provide the following documents:

- ID/Emergency Information
- Admission Agreement
- Physician's Report
- Psychiatric and Medical Notes/Orders
- Resident Appraisal
- Appraisal Needs & Service Plan
- Progress Notes
- Medication Records
- Personal Property Record
- Weight Record
- Laboratory Paperwork
-Staff schedule

An exit interview was conducted, this report was discussed with the facility Administrator Marilyn Jimenez and a copy of this report was provided during this visit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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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