<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800040
Report Date: 06/16/2022
Date Signed: 06/16/2022 12:44:51 PM

Document Has Been Signed on 06/16/2022 12:44 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:BENTON HOUSEFACILITY NUMBER:
496800040
ADMINISTRATOR:FAIRCHILD, CARRIEFACILITY TYPE:
735
ADDRESS:325 MAJOR DRIVETELEPHONE:
(707) 523-3672
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 6CENSUS: 6DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Edward Bechtel-Residential SupervisorTIME COMPLETED:
12:55 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), Dina Alviso. LPA is conducting a Required - 1 Year Inspection, on 6/16/22 and met with Edward Bechtel, Resident Supervisor. Inspection is focused on the Infection Control procedures and practices of this facility.

Currently six(6) clients in care. Caregiver Elizabeth screened the LPA before they entered into the home.

Fire clearance approval is for four(4) ambulatory and two(2) non-ambulatory clients-effective 9/16/21. Fire extinguishers were current, serviced and tagged as required, dated 10/18/21; The fire extinguishers will be serviced next week per Resident Supervisor. All seven(7) smoke alarms were working properly during the LPA's inspection. The two(2) carbon monoxide detectors were working properly during the inspection. All visitors are screened upon entering the home. All visitors have their temperatures taken and answer screening questions. Clients are screened daily, and observed for any changes. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored inaccessible and in locked cabinets. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. The facility has a large sufficient supply of personal protective equipment (PPE). All postings were up and visible to all as required. All three staff were observed to have masks on during the LPA's inspection.

LPA observed in the staff area room two small cameras set up and in each camera was showing a resident in their bed sleeping; The caregiver told the LPA it was to keep an eye on the resident, including when doing other duties such as cooking, and other things.
continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BENTON HOUSE
FACILITY NUMBER: 496800040
VISIT DATE: 06/16/2022
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
26
27
28
29
30
31
32
The caregiver stated that if they get up or need help/assistance the staff person can see and/or if they have a fall . Resident Supervisor arrived to the facility and had the caregiver remove the cameras from client bedrooms (two client rooms. LPA discussed with the caregiver and Resident Supervisor regulations regarding personal rights and staffing. If staffing is needed during certain times of the day, have staff come in do not use cameras as a way to supervise clients in care. Resident Supervisor will discuss with Sherri Kimaball Executive Administrator regarding staffing and client care plans. Resident Supervisor stated his understanding to the LPA of the above discussed.

Regarding the cameras set up in resident's bedrooms, which violates resident's personal rights, the LPA will be citing this violation, Personal rights 80072(a)(1)-see LIC809D.


The following deficiency(s) was/were cited (see LIC809D) from the California Code of Regulations, Title 22, Division 6 of California Regulation.

Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/16/2022 12:44 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/16/2022 at 12:26 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BENTON HOUSE
FACILITY NUMBER: 496800040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80072(a)(1)
80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation and interviews, the licensee did not comply with the section cited above iby having two camera's set up ito watch over two clients each in their bedrooms, this is an area that privacy is expected, if additional staff is needed address this and ensure staffing is provided, this deficiency poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/23/2022
Plan of Correction
1
2
3
4
Licensee/Administrator to provide how the facility staff will ensure that the personal rights of residents are not violated at any tiime; Submit what plan has been put in place regading the two residents and their care plans, include if staffing has been adjusted to ensure needs of the resident are being met. POC due 6/23/22.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3