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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608988
Report Date: 01/08/2021
Date Signed: 01/20/2021 12:04:12 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: 3DATE:
01/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Mona AlcarazTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management - Other Visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with Mona Alcaraz facility administrator.

On 01/07/2021, the Long Term Care Ombudsman (LTCO) were denied entry into the facility by staff Ma.Sheila Awingan and Director of Operations Joseph Chan.

Deficiencies are being cited based on LPA interviews and record reviews in accordance with the California Code of Regulations, Title 22, please see LIC809-D.

A telephonic exit interview was conducted, Appeal Rights and a hard copy of this report was provided via email for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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: 01/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
01/11/2021
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours...upon.
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This requirement was not met as evidence by:
Based on interviews and record reviews conducted, the licensee failed to ensure that the Long Term Care Ombudsman were permitted to visit the residents on 01/07/2021, which poses a potential health and safety 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2021
LIC809 (FAS) - (06/04)
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