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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803579
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:30:08 PM

Document Has Been Signed on 12/21/2022 12:30 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:BENSHANTE PLACEFACILITY NUMBER:
496803579
ADMINISTRATOR:MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:500 LOS ARBOLES WAYTELEPHONE:
(707) 978-5989
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 3DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Debbie Miller-AdministratorTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Alviso conducted a Required1 Year inspection, on 12/21/22, and met with live-in caregiver Sam Beehner. Sam contacted live-in caregiver Melanie Valenti Beehner, and Licensee/Administrator Debbie Miller. Administrator came to the facility to meet with the LPA, and Caregiver Melanie arrived a short time after the Administrator. Caregiver Jeremy Morphis arrived with Melanie. There are three clients in care; All clients at day program.

All staff have required criminal record clearance. All staff have current first aid certification. LPA reviewed staff training. Debbie Miller has required current Administrator Certificate #6010716735 -expires 2/3/2024. LPA discussed infection control plan, policies and procedures of the facility; Caregiver stated their understanding of the facility's infection control plan.

LPA toured the facility with Caregiver Melanie. All exits were unobstructed. Fire extinguisher was serviced and tagged as required -dated 12/22/2022. The carbon monoxide detector was checked and working during the inspection. All medications were locked up and inaccessible to clients in care. The facility has a sufficient supply of personal protective equipment(PPE).

No deficiencies cited in today's inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2022
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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