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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608988
Report Date: 08/19/2021
Date Signed: 08/19/2021 04:36:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:BENTLEY HILLS BY SERENITY CARE HEALTHFACILITY NUMBER:
197608988
ADMINISTRATOR:OGBECHIE, BIOSEHFACILITY TYPE:
740
ADDRESS:3121 CASTLE HEIGHTS AVENUETELEPHONE:
(213) 478-0472
CITY:LOS ANGELESSTATE: CAZIP CODE:
90034
CAPACITY:6CENSUS: DATE:
08/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver, Ma.Sheila AuinganTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Troy Agard conducted an unannounced Case Management POC visit to Bentley Manor By Serenity Care Health. LPA arrived and met with Caregiver, Ma.Sheila Auingan. LPA explained the reason for the visit.

On 08/02/2021, LPA Agard conducted a case management visit and cited the facility for failing to provide proof of liability insurance coverage under HEALTH & SAFETY CODE 1569.605 LIABILITY INSURANCE: COVERAGE REQUIREMENTS.

On 08/19/2021, LPA Agard conducted a follow up Case Management POC follow up visit with the facility to ensure that the requirement has been met and the facility is in compliance.

During the visit, LPA spoke with Administrator, Mona Alcarez (via telephone) and advised LPA that the corporate office is still handling the liability issue coverage and was unable to provide LPA with any documentation.

The facility failed to comply with the POC that was issued on 08/02/2021 and new citations are being issued under regulation. 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.


A copy of the report was issued to Mona Alcarez
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY HILLS BY SERENITY CARE HEALTH
FACILITY NUMBER: 197608988
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited

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Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million
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dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement has not been met: Based on observation and interviews conducted the failed to provide proof of liability
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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: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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