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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604617
Report Date: 12/20/2024
Date Signed: 12/20/2024 04:45:08 PM

Document Has Been Signed on 12/20/2024 04:45 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:BENEVOLENCE HOME CAREFACILITY NUMBER:
374604617
ADMINISTRATOR/
DIRECTOR:		VELASCO, JOFELFACILITY TYPE:
735
ADDRESS:922 MELROSE AVENUETELEPHONE:
(619) 240-7094
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Raquel Ceballos and Administrator Jofel VelascoTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alma Raquel Ceballos. LPA then met with Licensee/Administrator Jofel Velasco, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of four (4) clients, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. Per LIC602 Physician’s Reports, staff interviews, and LPA observation: During today’s inspection, there were a total of four (4) clients in care [Client #1 (C1), Client #2 (C2), Client #3 (C3), and Client #4 (C4)], of whom all were non-ambulatory. [See LIC811 Confidential Names List pages of a description of select person identifiers used in this report.] The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present.

During today’s visit, LPA performed a welfare check and interviewed multiple clients and multiple staff. LPA reviewed the care records for all clients and personnel records for all active staff. LPA, accompanied by staff, also toured the interior and exterior of the facility, and inspected all common areas and client bedrooms.

The facility’s ambient internal temperature was complaint at 73 F. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra supplies of linens, toiletries, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Appliances to preserve perishable food were also compliant in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 5
Document Has Been Signed on 12/20/2024 04:45 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/20/2024 at 03:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BENEVOLENCE HOME CARE
FACILITY NUMBER: 374604617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water delivered to plumbing fixtures used by clients to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential health risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 12/20/2024
Plan of Correction
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During today's visit, adjustments were made to the facility's water heater, such that hot water at all taps used by clients were brought back into the range required by regulation. This resolved the deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2024 04:45 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/20/2024 at 03:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BENEVOLENCE HOME CARE
FACILITY NUMBER: 374604617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more clients in the facility are diagnosed with a contagious disease, the following shall apply:  (2) All staff and volunteers providing direct care to a client who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth.  PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.  (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around clients and annually thereafter. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews, Licensee did not ensure that 8 of 8 facility staff (Staff #1 through Staff #8) were trained in the proper use of all required PPE annually. This posed a potential health risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee agreed to conduct PPE training for all current staff. The training will include hands-on practice and will cover: a) how perform an N-95 seal check, b) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, and c) how to set up and manage an isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repreat this training at least annually.
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interviews, Licensee did not ensure that 8 of 8 facility staff (Staff #1 through Staff #8) were trained on the facility's written emergency and disaster plan at least annually. This posed a potential safety risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee agreed to train all current staff on the facility's LIC610D Emergency and Disaster Plan. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repreat this training at least annually.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/20/2024 04:45 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/20/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BENEVOLENCE HOME CARE
FACILITY NUMBER: 374604617

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not conduct disaster drills at least quarterly for each shift. Licensee also did not vary the type of emergency covered from quarter to quarter. This posed a potential safety risk to 4 of 4 clients (Client #1 through Client #4) in care.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee agreed to conduct, and document in writing, completion of three (3) disaster drills (one for AM shift, one for PM shift, and one for NOC shift). Licensee agreed to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of emergency covered from quarter to quarter.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BENEVOLENCE HOME CARE
FACILITY NUMBER: 374604617
VISIT DATE: 12/20/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition were kept at the facility. No pools or bodies of water were observed on the premises. The facility’s fireplace was screened, as required. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. Licensee presented proof of current business liability insurance and surety bond.

Hot water temperature at taps accessible to clients were initially too hot in temperature: Kitchen Sink was 128.8 F, Bathroom #1 Sink was 130.8 F, and Bathroom #2 Sink was 125.6 F. Regulation required that these taps not exceed 120 F. (During today’s visit, adjustments were made to the facility’s water heater to bring each of these taps back into the complaint range.)

During a review of personnel and training records, LPA observed, and manager interview confirmed: Licensee did not have proof that direct care staff had been trained on PPE within the last year, as required. Licensee did not have proof that direct care staff had been trained on the facility’s written LIC610D Emergency and Disaster Plan (and their responsibilities under it) within the last year, as required. While Licensee performed some disaster drills over the past year, they fell short of the required frequency of one drill per shift, per quarter. The completed drills also did not “[take] into account different emergency scenarios,” as required by regulation.

Two (2) deficiencies were cited per California Code of Regulations, Title 22, and two (2) deficiencies were cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding staff alert devices on exterior exit doors and a Mandated Reporter training refresher for line staff (refer to the LIC9102-TA page).

An exit interview was conducted with Jofel Velasco. A copy of this report, the LIC 809-D pages, the LIC9102-TA pages, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
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