195850277-7-25-2022-29-AS-ECAS-CGP2YT-20220725174916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 07/25/2022
Date Signed: 07/25/2022 05:50:09 PM

Document Has Been Signed on 07/25/2022 05:50 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BENTLEY HILLS		FACILITY NUMBER:	195850277
ADMINISTRATOR:	AQUINO, ROBIN		FACILITY TYPE:	740
ADDRESS:	22740 HATTERAS STREET		TELEPHONE:	(213) 478-0460
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 3	DATE:	07/25/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Belen Taico and Stephany Perez		TIME COMPLETED:	06:00 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 Analyst (LPA) Elsie Campos arrived at the facility announced at 2:05 p.m. to conduct a pre-licensing inspection. The LPA met with Applicant Representatives Belen Taico and Stephany Perez. This is a change of ownership application from Hannah’s Home by Serenity Care Health (#197609122) to Bentley Hills (#195850277). The current census for six (6) residents, the facility currently has three (3) residents. The fire clearance was granted on 06/15/2022; in which all rooms were cleared for non-ambulatory clients and in which a bedridden person is permitted in Bedroom #1. Applicant successfully completed Component II on 07/18/2022 and completed Component III on 7/25/2022. The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in the cabinet under the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. BEDROOMS: There are six bedrooms in the facility all for resident use. The facility has one staff bedroom that is being used by former staff as a private living quarter. The staff room is accessed through an attached staff bathroom which was not locked and contained accessible disinfectants. All rooms have direct access to the outside. Lighting in the rooms appeared adequate. Resident room #2, #4. #5 and #6 were set up with beds, night stands, lamps, chests of drawers, chairs, and closet space. Resident bedroom #1 and #3 were not set up with a bed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BENTLEY HILLS	FACILITY NUMBER: 195850277
	VISIT DATE: 07/25/2022

NARRATIVE

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BATHROOMS: There are four (4) full bathrooms. There are two (2) private bathrooms for resident use; there are (2) full bathrooms in the hallway that are designated for residents, staff and guests. Resident bedroom #1 and #2 have an attached bathroom for private use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature measured in bathrooms measured between 128.2 – 137.6 degrees Fahrenheit. Applicant attempted to regulate water temperatures during visit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and a cabinet with games and activities for resident use. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. The fire extinguisher was fully charged and last serviced 12/22/2021. There is a functioning telephone on the premises.

Emergency exiting plans/sketch are posted in the facility hallway. Emergency telephone numbers are posted in the facility hallway. Other required postings are posted in the hallway and upon entry into the facility.

MEDICATIONS: Medications are in a storage room in the kitchen which is locked and inaccessible to residents in care. The first aid supplies were complete.

FILES: Resident and staff records are stored in a filing cabinet in the office located at the back of facility.

LAUNDRY: The laundry area is located in a storage room in the kitchen which is locked and inaccessible to residents in care.

GROUNDS: The facility has a covered car port. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time of the visit.The LPA observed a locked storage unit in the back yard containing additional supplies and yard equipment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BENTLEY HILLS	FACILITY NUMBER: 195850277
	VISIT DATE: 07/25/2022

NARRATIVE

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INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Elsie Campos within 10 days:

- Documentation of water temperatures meeting Title 22 regualtions.
- Photos that window screen in room 6 was fixed.
- Documentation that the bathroom at facility entry has been made inaccessible to residents in care.
- Photos of fully furnished bedrooms

Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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