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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 12/13/2022
Date Signed: 12/13/2022 12:03:52 PM


Document Has Been Signed on 12/13/2022 12:03 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 HILLSFACILITY NUMBER:
195850277
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:22740 HATTERAS STREETTELEPHONE:
(213) 478-0460
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 2DATE:
12/13/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Julieta Cruz and Robin AquinoTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a Post Licensing at 8:10 a.m. When the LPA arrived, there was one staff and two residents present. The LPA was greeted by staff Julieta Cruz and informed them of the reason for the visit. Administrator Robin Aquino was notified of the LPA’s visit, but was unable to come to the facility at that time.

The LPA, along with staff Julieta Cruz, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals were locked inaccessible in the kitchen cabinets. Appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food.

BEDROOMS: There are six (6) bedrooms in the facility for resident use. The facility has a separate staff unit, which had its own bathroom and living quarters. The staff room was accessed through an attached bathroom which was locked. The LPA toured the staff quarters and observed it to be empty at the time of the visit.

The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. All direct exits were clear, and no obstructions were noted.

RESTROOMS: The resident restrooms were clean and sanitary with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. At 10:30 a.m., water temperature measured in the common hallway restroom at 110.5 degrees F. Hand-washing signs were observed in the restrooms.

COMMON AREAS: Living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 12/22/2021. The LPA observed required postings throughout the common space. The supply closet/staff area adjacent to the kitchen was locked at the time of the visit.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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: 12/13/2022
NARRATIVE
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The backyard has a covered outdoor area with furniture for resident use. There was a self-latched side gate. No bodies of water noted. There was a covered carport. There was a locked storage unit with supplies.

RECORDS: At 8:20 a.m., two (2) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Two (2) out of two (2) residents (Resident #1, Resident #2) require updated appraisals. One (1) out of two (2) residents (R1) requires an updated medical assessment. One (1) out of two (2) residents (2) were on hospice; but, there was not an updated hospice care plan on file.

One (1) personnel file was reviewed for, but not limited to: personnel records, health screening, criminal record clearances, first aid/CPR training. Staff #1 (S1) needs a completed criminal record statement.

The Administrator was advised to post the new license for this location. The Administrator was advised to review the signage throughout the facility and to remove information that pertains to the former licensee/facility.

MEDICATIONS: Medications review began at 9:40 a.m.; medications are centrally stored and locked in a cabinet the staff room. Current medications for R1 and R2 were not properly documented on the centrally stored medications and destruction record. The following was noted:


    · A pill count indicated that staff assisted R1 with the self-administration of the as-needed (PRN) medication Acetaminophen 17 times. Yet a review of the PRN log indicated that staff documented that they assisted R1 with this medication 19 times.

    · A pill count indicated that staff assisted R2 with the self-administration of the as-needed (PRN) medication Alprazolam 24 times. Yet a review of the PRN log indicated that staff documented that they assisted R1 with this medication 23 times.

    · A pill count indicated that staff assisted R2 with the self-administration of the as-needed (PRN) medication Seroquel 26 times. Yet a review of the PRN log indicated that staff documented that they assisted R1 with this medication 13 times.

    · Although R1 and R2 have PRN (as-needed) medications, the LPA observed that staff had already prepared R1 and R2’s evening medications and placed them in a pill cup, which included the PRN medications. Staff claimed that R1 and R2 need the PRN medications. The LPA observed the PRN log for R1 and observed that staff had pre-written the dosage for 5 p.m. for R1’s acetaminophen.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
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: 12/13/2022
NARRATIVE
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INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and temperature checks. Staff were wearing appropriate face coverings and the LPA was screened upon entry. There was hand sanitizer available throughout the facility. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/13/2022 12:03 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited

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87465(d)(3) Incidental Medical and Dental Care. The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Host an in-service training from an appropriately skilled professional regarding PRN medication and medication documentation. It must be scheduled within the next two days, and must take place in the next two weeks.
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Based on medication review, the licensee did not comply in the section cited above for two out of two (R1, R2) residents as it pertains to documentation for assisting residents with the self-administration of PRN medication, which poses an immediate health and safety risk to residents in care.
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Include all staff that assist with the self-administration of medication. Inform CCL of the date of the training no later than 12/15/2022. Training must happen before 12/30/2022.
Type B
12/30/2022
Section Cited

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87465(h)(6) Incidental Medical and Dental Care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes…
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Update the forms and submit to CCL no later than 12/30/2022
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Based on medication review, the licensee did not comply with the section cited above for two out of two (R1, R2) residents, as medications were not documented on the centrally stored forms, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 12/13/2022 12:03 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited

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87705(c)(5) Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Update the forms and submit to CCL no later than 12/30/2022
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Based on record review, the licensee did not comply with the section cited above for two out of two (R1, R2) residents, as R1 needs an updated appraisal and medical assessment, and R2 needs an updated appraisal which poses a potential health and safety risk to residents in care.
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Type B
12/30/2022
Section Cited

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87355(d) Criminal Record Clearance. All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Have S1 complete the form and submit to CCL no later than 12/30/2022
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Based on record review, the licensee did not comply with the section cited above for one out of one (S1) staff, as S1 did not have a completed criminal record statement on file, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 12/13/2022 12:03 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited

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87633(b) Hospice Care of Terminally Ill Residents. A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following…
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
Send the updated hospice care plan for R2 to CCL by 12/30/2022
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Based on medication review, the licensee did not comply with the section cited above for one out of two (R2) residents, as R2’s hospice care plan on file was issued May 2021, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6