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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 11/06/2023
Date Signed: 11/06/2023 03:47:02 PM


Document Has Been Signed on 11/06/2023 03:47 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
WOODLAND HILLS N.ASC, 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:
11/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Vanessa Barcela Haavsgard, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Emily Peraldi conducted a Case Management - Deficiencies visit in conjunction with a complaint visit. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

Prior to visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Upon arrival, it was revealed Staff #1 (S1) was recently hired. Per record review, conducted by the LPA on the Guardian Background Check System website, S1 did submit fingerprint clearance but the clearance is still pending. Additionally, S1 is not associated to the facility. Interviews with the Administrator revealed that S1 started working at this facility around October 2023. The Administrator stated that she will ensure that all staff will have a criminal record clearance and are associated to the facility prior to working at the facility.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiency was cited (refer to LIC 809-D). Civil Penalty assessed in the amount of $500. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of today's reports and appeal rights were provided. Civil penalties issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
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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Document Has Been Signed on 11/06/2023 03:47 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: BENTLEY HILLS
FACILITY NUMBER: 195850277

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2023
Section Cited
CCR
87355(e)(1)

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87355(e)(1)Criminal Record Clearance (e) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee agreed to resubmit a criminal record clearance for S1 by 11/07/2023.

Civil Penalties assessed in the amount of $500.
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Based on record review and interview the licensee did not comply with the section cited by not ensuring that S1 has a criminal record clearance which poses an immediate health, safety and personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
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