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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803579
Report Date: 12/12/2023
Date Signed: 12/12/2023 01:40:31 PM

Document Has Been Signed on 12/12/2023 01:40 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:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Melanie Beehner-CaregiverTIME COMPLETED:
01:36 PM
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Licensing Program Analyst(LPA), Alviso conducted a Required - 1 Year Inspection, and met with live-in caregiver, Melanie Beehner. All clients were at day program during the inspection.

Facility has an infection control plan as required. Fire clearance approval is for four (4) ambulatory. All exits were cleared and free of obstruction. Fire extinguishers, 1, was serviced and tagged as required. Emergency fire drill was held on November 14, 2023.
LPA reviewed three (3) resident files. Files were complete.
LPA reviewed five (5) staff files. All staff had required criminal record clearance. All staff had required training.
All medications were locked up and inaccessible to residents in care. All toxins were locked up and inaccessible to residents in care. All exits were unobstructed. Hot water was checked at 116.7 degrees Fahrenheit. There is sufficient lighting in the hallways, bathrooms, and common areas, as well as client rooms. Food supply was sufficient, and staff stated tomorrow, Wednesday, is shopping day. There was sufficient furnishings for 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

Per facility file review and interviews with staff, the facility lacked the emergency and disaster plan as required. The following deficiency was cited, H&S Code1565(a), A facility shall have an emergency and disaster plan as required by H&S, see LIC809D.

The following deficiency was cited 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 Melanie Beehner, caregiver. Appeal rights provided for the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023
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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Document Has Been Signed on 12/12/2023 01:40 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/12/2023 at 12:48 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: BENSHANTE PLACE
FACILITY NUMBER: 496803579

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's facility file review and interviews with staff, the facility lacked the emergency and disaster plan as required, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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Licensee/Administrator to complete a facility emergency disaster plan as required. Review the plan with all staff, and ensure that any newly hired staff are trained as well. Once trained, ensure this training is done annually with all staff. Submit copy of the emergency disaster plan to the Licensing office. POC due 12/29/23.
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: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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