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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 09/17/2021
Date Signed: 10/01/2021 02:13:11 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2020 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200319162250
FACILITY NAME:BENTLEY SUITES BY SERENITY CARE HEALTHFACILITY NUMBER:
197609123
ADMINISTRATOR:MONA ALCARAZFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0800
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 24DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eva BataTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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Residents sustained unexplained injuries
Staff refused resident access to the dining room
INVESTIGATION FINDINGS:
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On 9/17/2021 at 12:00pm, Licensing Program Analyst (LPA)/Susan Campos, conducted a subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA was allowed entry into the facility by Eva Bata, Facility Manager. LPA explained to Ms. Bata the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (5) staff members and (2) residents on 3/31/20, and (4) residents on 7/30/21. In addition, on 3/31/20, LPA and Renel Cabral, former facility manager, conducted an inspection, for health and safety, of the facilities’ physical plant, and food supply. The common areas included: office, dining room, kitchen, TV room, and outdoor patio. LPA also reviewed the following documents provided by Bentley Suites Renel Cabral, Adminisrator: Staff roster, Client roster, Staff schedule, TV room usage policy, COVID 19 dining room policy, Meal-time service, staff and resident incident reports, list of all staff, and residents including telephone numbers.

Report continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2020 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200319162250

FACILITY NAME:BENTLEY SUITES BY SERENITY CARE HEALTHFACILITY NUMBER:
197609123
ADMINISTRATOR:MONA ALCARAZFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0800
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 24DATE:
09/17/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Eva BataTIME COMPLETED:
01:48 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide food to resident in care
Staff hit resident
INVESTIGATION FINDINGS:
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3
4
5
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7
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13
On 9/17/2021 at 12:00, Licensing Program Analyst (LPA)/Susan Campos, conducted a subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA was allowed entry into the facility by Eva Bata, Facility Manager. LPA explained to Ms. Bata the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (5) staff members and (2) residents on 3/31/20, and (4) residents on 7/30/21. In addition, on 3/31/20, LPA and Renel Cabral, former facility manager, conducted an inspection, for health and safety, of the facilities’ physical plant, and food supply. The common areas included: office, dining room, kitchen, TV room, and outdoor patio. LPA also reviewed the following documents provided by Bentley Suites Renel Cabral, Facility Manager: Staff roster, Client roster, Staff schedule, TV room usage policy, COVID 19 dining room policy, Meal-time service, staff and resident incident reports, list of all staff, and residents including telephone numbers.

Report continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20200319162250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/17/2021
NARRATIVE
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Allegation: Staff did not provide food to resident in care

The investigation revealed, per LPA interviews, with (5) staff members, and (6) residents from the Bentley Suites facility that the facility provides food to it’s residents. In addition, S1 informed LPA, that the facility offers the residents meals, and that the facility has food. S1 informed the LPA that a menu is posted, in the dining room, and that meals are served, during breakfast, lunch and dinner. The LPA interviewed (5) Bentley Suites staff personnel and 5 of the 5 staff members interviewed, informed LPA, that the residents are provided meals and snacks every day. Also 5 of 5 staff persons informed LPA, that they are not aware, of a resident, that was not provided food in the facility. In addition, LPA was informed by 5 of 5 facility staff persons that the facility has food in the facility. Furthermore, LPA interviewed (6) residents and 6 of 6 residents interviewed, informed LPA, that the facility has food, and serves resident food during mealtime. In addition, 6 residents were interviewed, 6 of 6 residents, informed LPA, that the facility has designated mealtime breakfast, lunch and dinner, and has a menu posted in the dining room. Also LPA interviewed 6 residents, and 5 of 6 residents informed LPA that there has never been a case that the facility has not served food to a resident. On 3/31/20, LPA observed, per virtual video conference, with Renel Cabral, Facility manager, the kitchen, and the LPA observed that there is sufficient perishable and non-perishable food available and maintained properly per title 22 guidelines.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff did not provide food to resident in care ”.

Allegation: Staff hit resident

The Department of Social Services Investigation Branch's Department conducted interviews with Bentley Suites, staff, residents, and resident family members, and review of resident documents, found there was no evidence to corroborate the allegation “Staff hit resident”.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff hit resident ”.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Eva Bata, Office Manager, and a hard copy of a LIC 9099 was provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20200319162250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 09/17/2021
NARRATIVE
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Investigation

Allegation: Residents sustained unexplained injuries

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 were injuries to residents, without explanation of what occurred. In addition, per investigation, 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 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. ***Case Management Visit will provide citation for Lack of Care"

Based on information gathered, LPA did find sufficient evidence to support allegation " Residents sustained unexplained injuries ”.

Allegation: Staff refused resident access to the dining room

LPA interviewed S1, and informed LPA, that R1 was not allowed to eat meals in the dining room, because R1 was sneezing, and that they did not feel it was safe for R1 to be in the dining room. Also, R1 informed LPA, that on 3/17/20, was not allowed dining room entrance, because had been sneezing, and that would need to eat food outside of dining room.

On 3/31/20 at 2:30 pm, LPA was informed by S1 that R1 was not allowed to eat in the dining room during meal hours because was sneezing.

Based on information gathered, LPA did find sufficient evidence to support allegation " Staff refused resident access to the dining room ”.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Eva Bata, Office Manager and a hard copy of a LIC 9099, LIC 9099D and appeal rights were provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200319162250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87468.1(3)
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87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.(3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:
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Administrator will provide LPA, per fax, staff sign in sheet of training hours and topics on reporting and preventing resident injuries.

LPA fax number (323) 981-1781.
POC Due Date is 10/1/21.
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Based on interviews, observation, and record review, conducted by the Dept of Social Services Investigation Bureaur, LPA was informed of substantiated findings that residents sustained unexplained injuries which poses a potential health risk to residents in care.
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Type B
10/01/2021
Section Cited
CCR
87468.1(2)
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87468.1Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
87468.1Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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Administrator will provide LPA, per fax, staff sign in sheet of training hours and topics regarding resident personal rights for use of facility public space, and services.

LPA fax number (323) 981-1781.
POC Due Date is 10/1/21.
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Based on interviews, observation, and record review, on 3/31/20, LPA was informed by S1 that R1 was not allowed to enter dining room because R1 sneezes, thereby preventing resident from using dining room, and infringing personal rights. which poses a potential health risk to residents 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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 5