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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 09/24/2021
Date Signed: 02/10/2022 08:41:46 AM

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: DATE:
09/24/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Evacita Bata-House ManagerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Cifuentes, conducted an unannounced case management visit to this facility to ensure the Accusation/CDSS No. 6120010302E was posted as required by Law. In addition, to correct licensing reports originally issued on July 27, 2021, August 26, 2021, August 31. 2021 and September 8, 2021.

Upon arriving at the facility, the LPA met with House Manager Evacita Bata at 11:30am. The LPA explained the purpose for today’s visit is to correct licensing reports and issue deficiencies. During today’s visit physical plant was toured.

The Accusation was served to the Licensee "Serenity Care Health Corporation" via certified mail on June 16, 2021. The Accusation was not observed to be posted in a conspicuous location on July 27, 2021. The Licensee did not provide written notification to the residents, their responsible parties, or the long-term care ombudsman, as required. A copy of the Accusation was provided to staff. Staff were instructed to immediately post the Accusation.

Civil penalties will be assessed against any facility that fails to take corrective action within the described time periods. Per the California Health & Safety Code Section 1569.38, you are hereby notified that a $100 civil penalty will be assessed for the date July 27,2021 as Health & Safety Code Section 1569.38 requirements are not met. The total civil penalty for each day shall not exceed $100/day regardless of the number of notices the licensee fails to send that day. The total civil penalty for a continuous violation shall not exceed $5,000.



Continued on 809-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021
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 4
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
MONTERY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 09/24/2021
NARRATIVE
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Civil penalties will accrue until Community Care Licensing has received proof that all required parties have received written notification of the revocation action.

The following concerns were also observed during initial visits:


During tour of facility, LPA Cifuentes observed that elevator to second floor was not operable. House Manager Evacita Bata confirmed that the elevator was under repair and that a repairman had already been contacted.

The following deficiencies were cited, please see 809-D.

An exit interview was conducted and a copy of the report 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: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
MONTERY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/24/2021
Section Cited

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Health and Safety Code 1569.38 (b)(1) Posting of Licensing reports, disclosure to new residents: A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events; The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This requirement was not met, as evidenced by:
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Based on LPAs observations during initial visit on 7/27/2021 there was no supporting evidence provided to indicate that licensee notified residents/ responsible parties of the Accusation as required.
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Type B
09/24/2021
Section Cited

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Health and Safety Code 1569.38(e) Posting of Licensing reports, disclosure to new residents: Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, that may include where the mail boxes are located, where the facility license is posted, or any other easily accessible location in the facility. This requirement was not met, as evidenced by:
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Based on LPAs observations during initial visit 7/27/2021 the Accusation was not posted in a conspicuous location as required.
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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: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
MONTERY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2021
Section Cited

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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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During case managment visit on 7/27/2021 LPA Cifuentes observed that elevator to second floor was not operable. During today's visit on 9/24/2021, elevator is not operable This poses an immediate health and safety risk to residents in care.
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Type B
09/27/2021
Section Cited

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Health and Safety Code 1569.605 Liability insurance; coverage requirement; On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement was not met as evidenced by:
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Based on observations during initial visit on 7/27/2021, the licensee did not submit proof or verification of Liability Insurance. During today’s visit LPA has not obtained verification of Liability Insurance.
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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: 09/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4