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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608988
Report Date: 09/29/2021
Date Signed: 10/19/2021 08:11:57 AM

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: 4DATE:
09/29/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Caregiver, Sheila AuinganTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Troy Agard conducted an unannounced plan of correction (POC) visit to the above facility. LPA Agard arrived and spoke to Caregiver, Sheila Auingan. LPA explained the reason for the visit is to follow up on the Plan of Correction issued on September 24, 2021 and to confirm that the deficiencies have been corrected/cleared.

During today's visit LPA Agard confirmed that the following deficiencies have not been cleared:
-1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS: Licensee has failed to submit proof of liability insurance.

Civil Penalties assessed. Please see LIC421FC. An exit interview was conducted and appeal rights were provided to caregiver.
SUPERVISOR'S NAME: Angela J KendrickTELEPHONE: (323) 981-3347
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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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