197609123-3-12-2021-11-AS-MVAO-BZ6R7N-20210316124637

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 03/11/2021
Date Signed: 03/12/2021 04:43:01 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
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/26/2021 and conducted by Evaluator Stephanie Cifuentes

COMPLAINT CONTROL NUMBER: 11-AS-20210226135958

FACILITY NAME:	BENTLEY SUITES BY SERENITY CARE HEALTH		FACILITY NUMBER:	197609123
ADMINISTRATOR:	MONA ALCARAZ		FACILITY TYPE:	740
ADDRESS:	851 4TH STREET		TELEPHONE:	(213) 478-0800
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	44	CENSUS: 22	DATE:	03/11/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Renel Cabral-House Manager		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Toxic chemicals accessible to residents
Needles are not disposed appropriately
Facility is unkempt

INVESTIGATION FINDINGS:

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On 3/11/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an announced complaint tele-visit at this facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) Pandemic and to implement mitigation measures, today’s complaint investigation was conducted via Facetime Renel Cabral. LPA Cifuentes explained the purpose of today's visit was to deliver findings regarding the allegations listed above.

The investigation consisted of the following:

On 3/5/2021 LPA Cifuentes toured of facility grounds. LPA was shown 4 client bedrooms with attached bathrooms, lounge room, dining room, outside shaded area, and front of facility. During the visit LPA interviewed Administrator Renel Cabral and staff 1-staff 4. On 3/11/2021 LPA Cifuentes interviewed Resident 1-Resident 5. LPA requested and received the following documents: Staff roster and client roster.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210226135958

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: 03/11/2021

NARRATIVE

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Regarding the allegation: Toxic chemicals accessible to residents

The investigation revealed the following:

On 3/5/2021 LPA Cifuentes was given a tour of facility grounds. LPA did not see any toxic chemicals left in common areas, residents’ rooms, outdoor patio or facility entrance.

On 3/5/2021 LPA Cifuentes interviewed Administrator Renel Cabral regarding the allegation. Mr. Cabral told LPA that all toxins were kept locked in one of the two storage cupboards and always put away after use. He also added that nothing more than water or Pinesol was used in the

On 3/5/2021 LPA Cifuentes interviewed staff 1-4. Staff stated that cleaning products were always stored in storage cupboards after use.

On 3/11/2021 LPA Cifuentes spoke with Residents 1 -Resident 5. All 5 facility residents stated they had not seen any cleaning products left in their rooms of facility yard.

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.

Regarding the allegation: Needles are not disposed appropriately

On 3/5/2021 LPA Cifuentes spoke to administrator Renel Cabral regarding allegation. Mr. Cabral stated that only two facility clients receive injections. Those injections are not given by facility staff, but by LVN’s who come to the facility daily. When they are done giving the injections they come to the office and dispose of the needles in a sharps container that is stored in the office.

Continued on 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20210226135958

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: 03/11/2021

NARRATIVE

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On 3/5/2021 LPA Cifuentes toured facility grounds and was shown sharps container in administrators office. During facility tour LPA did not see any needles on grounds.

On 3/5/2021 LPA Cifuentes interviewed staff 1-staff 4. Facility staff told LPA they did not give clients injections, that and LVN did so, but that they all knew there was a box in the administrator’s office to dispose of needles.

On 3/11/2021 LPA Cifuentes spoke with Residents 1 -Resident 5. Of the residents interviewed, only two received injections and both stated they did not know how the needles where disposed of, but that they were not left in their rooms.

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.

Regarding the allegation: Facility is unkempt

On 3/5/2021 LPA Cifuentes spoke to administrator Renel Cabral regarding allegation. Mr. Cabral stated that the facility was cleaned daily.

On 3/5/2021 LPA Cifuentes toured facility grounds. Resident rooms and facility grounds were neat and tidy, with everything appearing to be in good condition.

On 3/5/2021 LPA Cifuentes interviewed staff 1-staff 4. Facility staff told LPA they believed facility was clean, while several added that the facility was cleaned daily.

On 3/11/2021 LPA Cifuentes spoke with Residents 1 -Resident 5. Of the residents interviewed, all stated they believed the facility was clean.

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.

A telephonic exit interview was conducted with Administrator Renal Cabral and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC9099 (FAS) - (06/04)

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