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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110162
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:17:19 PM

Document Has Been Signed on 09/07/2023 02:17 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BENJAMIN HOUSEFACILITY NUMBER:
490110162
ADMINISTRATOR:JOE GEISNERFACILITY TYPE:
735
ADDRESS:2297 W. HEARN AVENUETELEPHONE:
(707) 578-0238
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Joe Geisner (Licensee)TIME COMPLETED:
02:32 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Joe Geisner. Clients were attending to Day Program.

LPA/staff initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and pathways were free from obstructions. Client rooms are furnished per regulation. Water temperatures in client bathrooms read at 109.2 and 113 which is within regulation of 105 and 120 degrees F. At least two days of perishable and one week of non-perishable foods were available. Toxins are locked in a cabinet. Medications are centrally stored in locked cabinet and medication records were reviewed. Fire extinguishers were last inspected March 2023. Smoke detectors and carbon monoxide detector are wired located throughout the facility were tested and operational. Most recent Fire/Disaster drill was conducted 4/23. LPA/Licensee reviewed and discussed regulation that states to conduct a fire/disaster drill every quarter. Licensee agreed to conduct a disaster drill every quarter. Facility does have a current activity calendar and menu. Required postings were observed.

At 1:00 pm LPA conducted a file review of four client and three staff files. Clients records have updated care plans on file. CPR/1st aid certificates and training hours are current. Administrator Certificate for Joe Geisner 6016659735 expires 5/11/2024. Cash resources and documentation were reviewed.

Administrator agreed to submit updates of the following documents by 9/15/23: LIC500 (Personnel Report), LIC308 (Designation of facility responsibility), Surety bond, LIC400 cash affidavit for clients.

No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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