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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608988
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:33:55 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
MONTERY 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:
11/04/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Ma Sheila Auingan - House ManagerTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management visit to the facility Bentley Hills by Serenity Care Health. LPA Cifuentes arrived and spoke to House Manager Ma Sheila Auingan. LPA explained the reason for the visit is to follow up on citation issued on September 24, 2021.

During today's visit, LPA Cifuentes asked about the copy of liability insurance that was provided to LPA Troy Agard for BENTLEY HILLS BY SERENITY CARE HEALTH DBA Bentley Hills. The copy of the document provided to the LPA showed the coverage is 1 million per occurrence and 3 million aggregate for assisted living facilities - 3 locations. As of today's visit, no changes have been made to the liability insurance coverage provided to LPA Agard.

The facility has failed to comply with the POC that was issued on 09/24/2021. Additional citations are being issued under regulation 1569.605 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 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.

Civil Penalties assessed and an exit interview was conducted. House Manager Ma Sheila Auingan was provided a copy of the appeal rights
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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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