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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110162
Report Date: 09/16/2024
Date Signed: 09/16/2024 12:10:13 PM

Document Has Been Signed on 09/16/2024 12:10 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BENJAMIN HOUSEFACILITY NUMBER:
490110162
ADMINISTRATOR/
DIRECTOR:
JOE GEISNERFACILITY TYPE:
735
ADDRESS:2297 W. HEARN AVENUETELEPHONE:
(707) 578-0238
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 4DATE:
09/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rebecca Geisner-Live-in DSPTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
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Licensing Program Analysts (LPA), Alviso arrived to conduct a Required -1 Year inspection, on 9/16/24 at approximately 9:30am, and met with Lead DSP Rebecca Geisner. Rebecca is also a certified ARF Administrator. Stephanie Geisner Havens, DSP/Administrator arrived to meet with the LPA. Currently there are four clients in care; All clients were at day program.

Facility is fire cleared for three (3) ambulatory and three non-ambulatory (3) clients. There are four(4) clients in care. Fire/emergency drills are being conducted as required; Last drills were held on 3/15 and 4/20 of 2024. LPAs reviewed four (4) client files. All files were complete. LPAs reviewed two (2) staff files. All files were complete.
All exits were clear and unobstructed. Hot water was checked at 116.2 degrees Fahrenheit, which is within regulation. All fire extinguishers, two(2), were serviced and tagged as required. Facility has smoke alarms and carbon monoxide detector as required. Perishable and non-perishable food was sufficient. Sufficient supply of hygiene products, paper products, and disinfectant cleaners. Sufficient supply of linens. All medications were locked up, and inaccessible to clients in care. All disinfectants/cleaners were locked up and inaccessible to clients in care. Facility was at a comfortable temperature. The facility had sufficient lighting throughout the home, in bathrooms, resident rooms, common areas, and hallways.
LPA is requesting the following forms be updated and submitted by 10/16/24.
LIC 500 -Personnel Report
LIC 610D - Emergency Disaster Plan, Review & Update if needed- Submit updated plan to CCL
Infection Control Plan- Review & Update if needed- Submit updated plan to CCL
LIC 308 - Designation of Responsibility
LIC 400 Affidavit Regarding Client Cash Resources
Copy of Surety Bond
Copy of Administrator certificate

No deficiencies cited during today's inspection.
Exit interview conducted with Stephanie Geisner Havens, DSP/Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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