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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:26:32 PM


Document Has Been Signed on 08/24/2023 04:26 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: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Vanessa Barcela HaavsgardTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. Upon arrival, the LPA was greeted by the Administrator, Vanessa Barcela and at this time, the reason for the visit was explained. Entrance interview conducted.

The LPA 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: The LPA inspected the kitchen/food service area at 10:12 a.m. Knives and sharps were observed in a locked drawer by the kitchen island. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Cleaning supplies and toxins were observed locked under the kitchen sink inaccessible to residents in care.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature of 73 degrees Fahrenheit. At 10:28 a.m., smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed and fully charged on 06/15/2023. The LPA observed required postings throughout the common space. The facility has not been conducting earthquake drill quarterly. Activities were observed in the common areas. The LPA observed an adequate supply of emergency food and water. The LPA also observed cameras throughout the common areas.

RESTROOMS: The four (4) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. Two (2) resident restrooms are in the common areas and the other two (2) restrooms were observed in bedrooms #1 and #2. At 10:08 a.m., LPA observed White Rain Men’s Body Wash on bathroom #1’s counter. Additionally, at 10:15 a.m., LPA observed a bottle of mouthwash and Cetaphil skin cleanser on bathroom #2’s counter which were accessible to residents in care. Staff immediately locked items. (Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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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: 08/24/2023
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(Report Continued from LIC 9099C...)

The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all restrooms, and they measured between 105 – 120 degrees Fahrenheit at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with linens, appropriate furnishings, and sufficient lighting. At 10:25 a.m., LPA observed Resident #1 (R1) having their medication in their bedroom unlocked and accessible.

RECORDS: LPA reviewed Resident Records at 10:34 a.m. and Personnel Records at 11:16 a.m.

Four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan.

At 10:45 a.m., record review of R1’s Physicians Report (LIC 602A) dated 12/06/2022, indicates R1 is bedridden; however, during facility walkthrough, it was observed that R1 is not residing in bedroom #1 which is the only bedroom with fire clearance approved for bedridden. Additionally, per R1’s LIC 602A it also indicates R1 is able to administer own medications; however, R1 cannot store their own medications.

At 10:50 a.m., record review revealed one (1) out of four (4) residents is at risk if allowed direct access to personal hygiene and grooming items.

At 10:55 a.m., record review of R2’s Physicians Report dated 04/01/2023 indicates R2 has no capacity for self-care, is not on hospice, and the facility does not have an exception request on file with the Department that would allow facility to admit and retain R2 with a prohibited health condition.

Two (2) personnel files and Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Two (2) out of three (3) personnel files were missing the health assessments and criminal record clearances. Additionally, LPA was unable to determine the number of hours completed per regulation for the past 12 months.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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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: 08/24/2023
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(Report Continued from LIC 9099C...)

MEDICATIONS: Medications review began at 1:40 p.m. The medications are locked in an office adjacent to the kitchen. Medications are labeled and checked for expiration dates. At 1:47 p.m., LPA observed medications for two (2) out of four (4) residents that have writing added by facility staff.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promote good hand hygiene. 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 an infectious disease. 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. Immediate civil penalty issued today in the amount of $500 for fire clearance. 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 21
Document Has Been Signed on 08/24/2023 04:26 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.72(c)
Levels of Care
(c) Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. A fire clearance shall be issued to a facility in which one or more bedridden persons reside if either of the following conditions are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as R1 is bedridden but not residing in bedridden approved bedroom #1, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Administrator will have R1 moved to bedridden approbed bedroom #1 and send proof to CCL by 08/31/2023.
Type A
Section Cited
CCR
87615(a)(5)
Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as R2 has a prohibited health condition as LIC 602A states R2 has no capacity for self care and is not on hospice and facility does not have an exception on file which allows them to admit and retain R2 in the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Administrator will either submit an exception to retain R2 or will find a suitable place which will meet R2's needs.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 4 of 21


Document Has Been Signed on 08/24/2023 04:26 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as R1 has all medication in their room unlocked and accesible to other residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Administrator locked all medications at the time of visit.

POC has been met.
Type A
Section Cited
CCR
87705(g)
Care of Persons with Dementia
(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, the licensee did not comply with the section cited above as personal hygiene items were observed on bathroom counters and one (1) out of four (4) residents is at risk if allowed direct acces to personal hygiene items, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
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The Administrator locked items immediately.

POC has been met.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2023 04:26 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(b)(3)(B)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as two (2) out of three (3) personnel files are missing the LIC 508 for criminal record clearance, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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The Administrator will send copies of LIC 508 to CCL by poc due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as LPA was unable to determine the number of hours completed per regulation for the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2023
Plan of Correction
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The Administrator will send proof of staff training to CCL by poc due date.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 6 of 21


Document Has Been Signed on 08/24/2023 04:26 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as there is no training for medication for atleaast one (1) staff present at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2023
Plan of Correction
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The Administrator will submit proof of medication training to CCL by poc due date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above as two (2) out of four (4) resident's medication have dates written on bottle by facility staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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The Administrator will read and review Regulation 87465 and submit statement of understanding to CCL by poc due date.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
Page: 7 of 21


Document Has Been Signed on 08/24/2023 04:26 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview conducted, the licensee did not comply with the section cited above as emergency drills are not being conducted quaterly as stated in title 22 regs, which posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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3
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The Administrator will conduct emergency drill and submit proof to CCL by poc due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
LIC809 (FAS) - (06/04)
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