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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803579
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:33:56 PM

Document Has Been Signed on 02/18/2025 02:33 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:BENSHANTE PLACEFACILITY NUMBER:
496803579
ADMINISTRATOR/
DIRECTOR:
MILLER, DEBBIEFACILITY TYPE:
735
ADDRESS:500 LOS ARBOLES WAYTELEPHONE:
(707) 978-5989
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Debbie Miller-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 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 Analysts (LPAs) Alviso and Contreras conducted a continued annual inspection, on 2/18/25 at approximately 12:15pm, and met with Administrator Debbie Miller. There are four clients in care.

Fire clearance approval is for four (4) ambulatory. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Fire extinguishers one (1), was serviced and tagged as required, dated 12/10/24. All exits were cleared and free of obstruction. Last emergency disaster drill was conducted on 11/9/2024. Administrator understands that the drills are held quarterly, ensuring one is an evacuation drill.
LPAs reviewed four (4) resident files, including medication records and storage of medications. P&I monies were intact and records were maintained as required.
LPA reviewed six (6) staff files. All staff had training, including first aid. All staff had criminal record clearance as required.
Hot water was checked at 112. degrees Fahrenheit. Facility was found to be at a comfortable temperature. Sufficient food supply. Sufficient hygiene products, cleaners/disinfectants, paper products, and furnishings for resident use. There was a sufficient supply of personal protective equipment (PPE).
Administrator to submit an updated lease agreement for the facility as the previous one has expired, per file review. Administrator has agreed to provide a new lease for the facility by 2/21/25.
LPA is requesting the following documents be updated and submitted by 3/18/2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Surety bond
Resident Roster
Copy of current Administrator Certificate.

No deficiencies cited during today's inspection.
Exit interview conducted with Administrator Debbie Miller.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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 1