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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 07/27/2021
Date Signed: 07/28/2021 08:07:14 AM



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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210719094111
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: 22DATE:
07/27/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Eva BataTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Facility has bed bugs
Facility's water heater is in disrepair

INVESTIGATION FINDINGS:
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5
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10
11
12
13
Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an initial complaint investigation at above facility. LPA arrived at facility and was greeted by manager Eva Bata . LPA explained the purposed of the visit was to deliver findings for the allegation listed above and was granted access to the facility.

The investigation consisted of the following:

On 7/27/2021 LPA Cifuentes conducted a tour of facility grounds. Facility is two stories and located in a residential neighborhood. Facility ground consists of living room, kitchen, dining room, 22 resident bedrooms with attached bathrooms, side yard with shaded area. LPA interviewed Manager Eva Bata, staff 1-staff 5 as well as resident 1 through resident 7. LPA reviewed facility files and requested and received the following documents: staff and client rosters, GAM visit summary for July 13, 2021

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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 6
Control Number 11-AS-20210719094111
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
MONTERY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 07/27/2021
NARRATIVE
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Regarding the allegation: Facility has bedbugs

The investigation revealed the following:

On 7/27/2021 at 10:16am LPA Cifuentes spoke with manager Eva Bata. Mrs. Bata told LPA that the facility had bedbugs but that a company was coming to spray. Mrs. Bata told LPA that one of the residents told her they saw bedbugs this month so they came out on July 13, 2021 and sprayed rooms 13, 12, 14, 21, and 22. Then on July 20, 2021 they did rooms 1, 2, 3, 4, 5, 6, 7.

On 7/27/2021 from 12:00pm to 12:45pm LPA reviewed facility records. LPA reviewed reports from GAM exterminating, which shows that on July 13th 2021 inspector found bed bug activity in units 22, 21, 12 and 13 in the form of droppings and eggs.

On 7/27/2021 from 11:18am to 12:00pm LPA Cifuentes interviewed resident 1 to resident 7. LPA asked residents if they had seen any bed bugs. Out of 7 residents interviewed, one stated they had seen a bed bug recently.

On 7/27/2021 LPA Cifuentes interviewed staff 1-5. LPA asked staff if the facility currently had bed bugs, and all 6 staff responded that the facility did not currently have bed bugs and that they had been spraying.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 9099D.



Continued on 9099-c
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20210719094111
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
MONTERY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 07/27/2021
NARRATIVE
1
2
3
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5
6
7
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Regarding the allegation: Facility's water heater is in disrepair

The investigation revealed the following:

On 7/27/2021 at 10:16am LPA Cifuentes spoke with manager Eva Bata. Mrs. Bata stated that no one has stated that there is a problem with the water.

On 7/27/2021 from 11:18am to 12:00pm LPA checked water temperature in 7 resident rooms. Water temperature ranged from 97.5F to 140F.

On 7/27/2021 from 11:18am to 12:00pm LPA Cifuentes interviewed resident 1 to resident 7. LPA asked residents if they had hot water. Out of 7 residents interviewed, 4 out of 7 stated they did not always have hot water.

On 7/27/2021 LPA Cifuentes interviewed staff 1-5. LPA asked staff if the facility had hot water. 2 out of 5 staff stated residents had to be bathed in another room as there is not hot water in their room.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 9099D.

An exit interview was conducted with manager Eva Bata and a hard copy was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Stephanie Cifuentes
COMPLAINT CONTROL NUMBER: 11-AS-20210719094111

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: 22DATE:
07/27/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Eva BataTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications are set up more than 24 hours in advance
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an initial complaint investigation at above facility. LPA arrived at facility and was greeted by manager Eva Bata . LPA explained the purposed of the visit was to deliver findings for the allegation listed above and was granted access to the facility.

The investigation consisted of the following:

On 7/27/2021 LPA Cifuentes conducted a tour of facility grounds. Facility is two stories and located in a residential neighborhood. Facility ground consists of living room, kitchen, dining room, 22 resident bedrooms with attached bathrooms, side yard with shaded area. LPA interviewed Manager Eva Bata, staff 1-staff 5 as well as resident 1 through resident 7. LPA reviewed facility files and requested and received the following documents: staff and client rosters, GAM visit summary for July 13, 2021
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20210719094111
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
MONTERY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 07/27/2021
NARRATIVE
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Regarding the allegation: Medications are set up more than 24 hours in advance

The investigation revealed the following:

On 7/27/2021 at 10:16am LPA Cifuentes spoke with manager Eva Bata. Mrs. Bata stated that medications are set-up no more than 1 day in advance.

On 7/27/2021 at 11:00am LPA viewed medications cabinet. LPA observed medications set-up for lunch, dinner and bedtime, but did not observe any set-up for other days.

On 7/27/2021 LPA Cifuentes interviewed staff 1-5. LPA asked staff if the medications are set-up more than twenty-four hours in advance. Of those interviewed 3 of the staff stated they did not know anything about medication set-up and the final two stated medications are set-up no more than 24 hours in advance.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



An exit interview was conducted with manager Eva Bata and a hard copy was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20210719094111
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
MONTERY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2021
Section Cited
CCR
87303(e)(2)
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Maintenace and operation
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water...atttain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement was not met as evidenced by:
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Manager shall record water temperatures of at least three bathrooms for the next 24 hours. If temperatures do not change, repairs to the water heater will be made. Proof of temperture and invoices for water heater repairs are to be submitted to CCLD via fax by the POC due date.
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Based on observation, LPA Cifuentes tested temperature of several resident bathroom faucets and found water to be below 105F in some and above 120F in others. This poses and immediate health and safety risk to residents in care.
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Type B
08/03/2021
Section Cited
CCR
87303(a)
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Maintenance and operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by
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Administrator will ensure the bed bug activity is eradicated. Facility will continue with a service agreement with a pest control contract to resolve bedbug issue. Copies of invoices and reports to be submitted to CCLD via fax by POC due date.
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Based on records review, LPA Cifuentes found that 7/13/2021, facility had bedbugs, as observed by exerminator company. This poses a potential health and safety risk for 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6