374602277-10-17-2023-18-AS-JSRS-CWQ278-20231017170820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602277
Report Date: 10/17/2023
Date Signed: 10/17/2023 05:08:25 PM

Document Has Been Signed on 10/17/2023 05:08 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BENCY'S RANCH		FACILITY NUMBER:	374602277
ADMINISTRATOR:	MARILYN B JIMENEZ		FACILITY TYPE:	735
ADDRESS:	731 W 16TH AVE		TELEPHONE:	(760) 743-8179
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY: 6		CENSUS: 5	DATE:	10/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Roland Javier, Lead Staff		TIME COMPLETED:	05:12 PM

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 Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Crystal Pablo, Caregiver, and was granted entry into the facility. LPA then met with Lead Staff, Rolando Javier and discussed the purpose of the visit. A tour of the facility was conducted inside and out. LPA, accompanied by Mr. Javier, conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. The facility is licensed to serve six (6) Developmentally Disabled Adults, two (2) of whom may be non-ambulatory in bedroom #1 and #2 only. The facility is a four (4) bedroom, three (3) bathroom two (2) story house. Three (3) bedrooms are private occupied and one (1) bedroom is shared, two (2) to a room. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Mr. Javier, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Facility provides each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 107.2 degrees F. The facility had a functioning carbon monoxide detector, multiple smoke detectors, and multiple operable fire extinguishers. Emergency drills are conducted quarterly and the last drill was on 10/1/2023.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BENCY'S RANCH	FACILITY NUMBER: 374602277
	VISIT DATE: 10/17/2023

NARRATIVE

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The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. P&I funds were audited and are kept separate from facility funds. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Medications are being dispensed according to physician orders.

No deficiencies were observed during today's visit. This report was discussed with Mr. Javier. A copy of this report along with LIC 811 was provided at the conclusion of the visit.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:	DATE: 10/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023

LIC809 (FAS) - (06/04)

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