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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412351
Report Date: 10/10/2023
Date Signed: 10/10/2023 11:01:18 AM

Document Has Been Signed on 10/10/2023 11:01 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BENSON HOUSE, INC #10FACILITY NUMBER:
336412351
ADMINISTRATOR:AURORA ARZATEFACILITY TYPE:
735
ADDRESS:68215 CORTA RD.TELEPHONE:
(760) 321-1579
CITY:CATHEDRAL CITYSTATE: CAZIP CODE:
92234
CAPACITY: 4CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Erica MataTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a case management visit on the health, safety, and welfare of residents in care. RIV RO, Community Care Licensing received an SIR on September 19, 2023 for Benson House #10. LPA met with the Administrator, Erica Mata. LPA was informed that four (4) residents currently reside at this facility, with a capacity of four (4). There were three (3) staff on duty during the time of the visit and two (2) residents at the facility at the time of the visit.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. LPA will conduct interviews with staff and residents.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Administrator, Erica Mata and a copy of this report is left with the her as evidence by her signature.


SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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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