197609123-10-1-2021-11-AS-SCAS-C7DT76-20211001142812

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 09/17/2021
Date Signed: 10/01/2021 02:30:32 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 SUITES BY SERENITY CARE HEALTH		FACILITY NUMBER:	197609123
ADMINISTRATOR:	RENEL CABRAL		FACILITY TYPE:	740
ADDRESS:	851 4TH STREET		TELEPHONE:	(213) 478-0800
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	44	CENSUS: 24	DATE:	09/17/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:06 PM
MET WITH:	Eva Cabral		TIME COMPLETED:	02:40 PM

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On 9/17/21, Licensing Program Analyst/ LPA Susan Campos, conducted a case management visit to provide a citation for "Lack of Care", identified in Department of Social Services Investigation Branch Department investigation findings:

The Department of Social Services Investigation Branch Department conducted interviews with staff, residents, and resident family members from the Bentley Suites facility. The Investigation Branch discovered, during the investigation proceedings, that there was also evidence, of care neglect for R2, former resident, who wandered into other resident’s rooms, uninvited, and in some cases getting into altercations with other residents, where there were resident injuries sustained. In addition, R2, had altercations with facility staff members resulting in injuries. The investigation also revealed that R2 appeared to lack hygiene care, and also R2 would urinate and defecate in facility public areas.

This investigation was a result of complaint 11-AS-20200319162250, and complaint findings were delivered LIC 9099 to Eva Bata, Facility Manager on 9/17/21. Deficiency cited today, was not on LIC 9099D 9/17/21 report, and thereby is delivered on LIC 809D

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit Interview was conducted and a copy of a LIC 809D and appeal rights was provided to Eva Bata, Facility Manager.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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 SUITES BY SERENITY CARE HEALTH	FACILITY NUMBER: 197609123
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/01/2021 Section Cited	1 2 3 4 5 6 7	87468.2(4)Additional Personal Rights of Residents in Privately Operated Facilities(a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.(2)To have their records and personal information remain confidential and to approve their release, except as authorized by law.(3)To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on interviews, observation, and record review, conducted by the Dept of Social Services Investigation Bureau Investigator, LPA was informed of investigation findings of substantiated findings of care neglect for R2, which poses a potential health risk to residents in care.	8 9 10 11 12 13 14
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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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC809 (FAS) - (06/04)

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