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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800040
Report Date: 06/12/2023
Date Signed: 06/12/2023 05:47:32 PM

Document Has Been Signed on 06/12/2023 05:47 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:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Catherine Brenegan-AdministratorTIME COMPLETED:
05:55 PM
NARRATIVE
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Licensing Program Analyst (LPA), Dina Alviso. LPA is conducting a Required - 1 Year visit, on 6/12/23, and met with Catherine Brenegan, Administrator. Brenegan's Administrator's certificate #6065221735, expires 8/27/2025.

LPA reviewed infection control regulations with the Administrator, and discussed signage posted up at the facility. The facility does have a required Infection Control Plan. Facility does have a Emergency Disaster Plan. The facility had an emergency fire drill on 3/16/23.
Facility has an approved fire clearance for four(4) ambulatory, and two(2) non-ambulatory clients; Room #4 is cleared for non-ambulatory use. There are currently six residents in care.

LPA reviewed six(6) client files. All files were found to contain necessary documentation.
There are five DSP on duty providing services to the clients. All staff have required criminal record clearance.

The LPA toured the facility with the Administrator. Hot water was checked at 108.F.
All exits were unobstructed. All four(4) fire extinguishers were serviced and tagged as required- expires 6/5/24. The facility had sufficient lighting in all client rooms, common areas and bathrooms. The facility had a sufficient supply of perishable and non-perishable food. The facility had a supply of food and water to meet the required supplies for a 72 hour shelter in place.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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 4
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: 06/12/2023
NARRATIVE
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The facility had a sufficient supply of hygiene products, cleaners, and paper products. The facility had a supply of PPE for use as needed. Medications were centrally stored, locked and inaccessible to clients in care. Toxins/cleaners were locked up and inaccessible to clients in care.

LPA is requesting the following forms be updated and submitted by 06/30/23:
· LIC 500 -Personnel Report
· LIC 610 - Disaster Plan
· LIC 308 - Designation of Responsibility
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond
· Infection Control Plan-if updated//any changes

LPA reviewed five(5) staff files. LPA observed the following deficiencies: One(1) staff, S4, out of five(5) staff files reviewed, lacked current first aid certification as required.This deficiency will be cited, 80075(f)-Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross, see LIC809D.

One(1) staff, S3, out of five(5) staff files reviewed, lacks an LIC503 Health Screening document as required, this deficiency will be cited, 80066(a)(10)-A health screening as specified in Section 80065(g), see LIC809D.

Two(2) staff, S2 & S3, lack current first aid certification out of five(5) staff files reviewed. this deficiency will be cited, 80066(a)(11)-Tuberculosis test documents as specified in Section 80065(g), see LIC809D.


The following deficiency(s) was/were cited (see LIC809Ds) 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 with the Administrator Catherine Brenegan. Appeal rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 06/12/2023 05:47 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/12/2023 at 05:06 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: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observed: One(1) staff, S4, out of five(5) staff files reviewed, lacked current first aid certification as required, the licensee did not comply with the section cited ,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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Licensee to ensure staff #4 obtains first aid certification. Submit a copyof the current first aid by 6/17/23. Submit plan of correction by 6/13/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/12/2023 05:47 PM - It Cannot Be Edited


Created By: Dina Alviso On 06/12/2023 at 05:06 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: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's (record review), the licensee did not comply with the section cited above in, One(1) staff, S3, out of five(5) staff files reviewed, lacks an LIC503 Health Screening document, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee to ensure staff #3 obtains a completed LIC503 Health screening report. Submit a copy of the current first aid by 6/17/23. Submit plan of correction by 6/13/23.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's (observation), the licensee did not comply with the section cited above in Two(2) staff, S2 & S3, lack current first aid certification out of five(5) staff files reviewed] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee to ensure staff #3 & #4 obtains a TB test & results as required by regulation. Submit a copy of the TB test & results, POC due 6/30/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023


LIC809 (FAS) - (06/04)
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