<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 09/28/2021
Date Signed: 11/01/2021 02:25:38 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 SUITES BY SERENITY CARE HEALTHFACILITY NUMBER:
197609123
ADMINISTRATOR:RENEL CABRALFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0800
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 24DATE:
09/28/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Evacita BataTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management POC visit to the facility Bentley Suites by Serenity Care Health. LPA Cifuentes arrived and spoke to house manager Evacita Bata. 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 Cifuentes confirmed that the following deficiencies have not been cleared:
-1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS: Licensee has failed to submit proof of liability insurance.
-87303(a) MAINTENANCE AND OPERATION: Licensee failed to keep facility safe and in good repair. LPA observed that facility elevator is not operational.

Civil Penalties assessed. Please see LIC421FC. An exit interview was conducted and appeal rights were provided to House Manager Evacita Bata.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1