Benevolence Board & Care

Type of visit: Case Management - Licensee Initiated

On 05/30/2025 at 9:16 AM, Licensing Program Analysts (LPA) LaVette Farlow conducted an announced visit to confirm that all of the residents have been relocated in anticipation for the facility's relocation. LPA Farlow were granted entrance by Amanda Gonzales, Licensee. On 05/30/2025 at 9:20 AM, LPA Farlow conducted a tour of the home and observed that there are no more residents living in the facility. The licensee is initiating this closure and relocating to a new facility named Benevolence Board & Care II. LPA inspected the entire facility which included the 5 bedrooms, 2 bathrooms, living room, dining area, kitchen, office and the backyard. There were no residents present, and there were no belongings of residents in the facility. Licensee Amanda Gonzales stated that the reason for the relocation is due to the landlord not wanting to renew the lease agreement. Licensee Amanda Gonzales submitted the following during the closure plan. 1. Letters to residents indicating the closure, and letter to Community Care Licensing Division (CCLD). 2. Names of the five (5) residents (resident roster) and there location at Benevolence Board & Care II. Also, one (1) resident new location address and contact person. 3. Licensee surrendered the Hospice Waiver Approval letter from CCLD. Amanda Gonzales surrendered the original license to LPA Farlow. The effective date of closure will be 05/30/2025. An exit interview was conducted, where this report, LIC809 was discussed with and provided to Amanda Gonzales.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Sunarko Prabowo and introduced self and stated purpose of the visit. LPA ask staff to notify administrator of LPAs arrival. Licensee, Amanda Gonzales was called and spoke to LPA and later arrived. LPA was informed that there are currently 6 residents in care who are in the facility. The facility has 3 resident bedrooms, 2 resident bathroom, 2 staff bedroom, kitchen, dining area, living room, family room, laundry room, attached garage, backyard with a covered patio. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 80 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathroom; bathroom was clean and appliances were found functional. Water temperatures tested at 123.4, 126.4, and 124.3 degrees Fahrenheit. Which is out of range for regulation. LPA informed the licensee and she immediately adjusted the temperature. A deficiency was cited. The facility is equipped with operational smoke detectors, carbon monoxide alarms, fire extinguisher and first aid kit. Posters such as; the personal rights, ombudsman, CCL complaint poster and emergency disaster plans were posted in a common area. LPA also observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed secured and inaccessible to residents. There are no guns or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a wide variety of food available for residents. Dishes, cups, and utensils were also stored properly. Yards/Outside: One shaded patio, a side gate with self-latching handle on the right side of the house that leads into the backyard, no pool are bodies of water. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA reviewed guardian for criminal record clearance through the department. LPA observed that 1 out of three staff did not have the criminal record clearance. A deficiency was cites and a civil penalty will be assessed in the amount of two hundred dollars. Record Review: LPA reviewed four (4) out of four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) out of two (2) staff files. LPA observed personnel and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random for four (4) out of four (4) residents and LPA observed staff did not sign the MARS for 4 out of 4 residents for two days. The 24th and 25th of March. A deficiency was cited. LPA reviewed the facility's emergency disaster plan, infection control plan and emergency drills. Based on today's observation and interview with Licensee, a civil penalty will be immediately assess today in the amount of $200 dollars. If the deficiency is not corrected immediately, additional civil penalty will be accrues per day until corrected Three (3) deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC421BG and Appeal Rights were discussed and copies were provided to the Licensee, Amanda Gonzales.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Benevolence Board and Care facility unannounced to conduct the Annual Inspection. LPA was greeted by staff member, Agung. LPA introduced self and stated purpose of the visit. LPA was granted entry, while staff contacted Administrator, Amanda Gonzales. LPA spoke with Administrator over the phone who agreed to meet with LPA. Administrator arrived later during the visit. The facility has 5 bedrooms, 2 bathrooms, kitchen, dining area, living room, attached garage, and backyard. The facility maintains a partnership with Innovage Healthcare. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating at the capacity approved by Community Care Licensing (CCL). Pathways were observed to be free of obstruction. The facility observed in comfortable temperature. LPA inspected resident bedrooms and found that each room included required furniture such as: mattresses, night stands, adequate storage and sufficient lighting. LPA inspected resident bathrooms; each bathroom was equipped with handrails, medical durable equipment and non-slip grip materials for safety purposes. Bathrooms were observed to clean, appliances functional and included adequate amounts of hand hygiene and paper supplies. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted on a regular basis. Last fire/disaster drill conducted August 2023. Fire Extinguisher observed in the facility Dining Room; last inspected October 2023. Cleaning supplies, toxins, sharps, and other dangerous items were observed secure inaccessible to residents in care. Medications were secure and inaccessible to residents. The facility also maintains a secure refrigerator for medications. Emergency and first aid kits were observed and readily available for residents in care. Food Service: The facility maintains well stocked a pantry of dry good and non-perishable food items all in good standing. Inside the kitchen LPA observed dishes, cups, and utensils were observed in proper storage and in adequate amounts. Non-perishable and perishable food supply is sufficient for number of residents in care. Staff report that the facility maintains a weekly food menu in rotation; for breakfast, lunch, dinner and snacks. Facility offers its residents a variety of food items. Emergency food and water supply were also observed. Signs/Posters: LPA observed posters throughout the facility. Posters observed: LET-US-KNOW, Facility License, Resident Rights, Mandated Reports, Resident Council, Theft and Loss Infection Control Long Term Care Ombudsman and Oxygen Use. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week; as there are staff members who reside on facility property. Record Review: LPA reviewed resident files for Admissions Agreements, Updated Physician's Reports, Need and Services and CPR/First Aid. Two resident files contained Physician Reports which were not current. LPA reviewed staff files for First Aid/CPR Certification, Criminal Record Clearance, Training, and health screenings. LPA found that staff records included all documentation per regulation. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Based on observations, interviews and record reviews, 1 deficiency will be cited per Title 22, California Code of Regulations. An exit interview was conducted where this report was reviewed, discussed then provided to Facility Administrator.the state’s words, verbatim · CDSS document, Feb 27, 2024