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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850277
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:54:43 PM


Document Has Been Signed on 01/11/2024 05:54 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: 5DATE:
01/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Christian Havsgaard, ApplicantTIME COMPLETED:
06:00 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 deficiencies observed during the complaint investigation.

At 11:13 a.m., the LPA and Fire Inspector Pellegrini along with the Applicant conducted a physical plant tour. At 12:20 p.m., the LPA conducted an interview with the Applicant.

The following was observed during the time of the visit:
- Doorknobs throughout the facility need adjustments.
- The magnet hold door to room 4 does not close and latch properly.
- No building permit for the staff room at the back of the facility and the converted garage into a living room and additional room at the front of the facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/11/2024 05:54 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2024
Section Cited
CCR
87305(a)

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87305 (a) Alterations to Existing Buildings or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
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The Licensee agreed to do the following:
- The licensee representative believed that the garage converted rooms are permitted and will find the permit.
- Knock down the wall from the staff room located at the back of the facility.
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Based on observation and record review, the licensee did not comply with the section cited above in staff room located at the back of the facility and the living area and room located at the front are not permitted which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/19/2024
Section Cited
CCR87303(a)

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87303 (a) Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement is not met as evidenced by:
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The Licensee stated they will:
- Will fix the doorknobs, and room 4 door.
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Based on observation, the licensee failed to ensure that all door knobs throughout the facility are in good repair and the door to room 4 needs to close and latch properly which poses a potential health risk to clients 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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2