197609123-1-4-2022-11-AS-MVAO-CC4SBP-20220301124417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 01/04/2022
Date Signed: 01/04/2022 04:28:29 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
12/21/2021 and conducted by Evaluator Stephanie Cifuentes

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211221103200

FACILITY NAME:	BENTLEY SUITES BY SERENITY CARE HEALTH		FACILITY NUMBER:	197609123
ADMINISTRATOR:	RENEL CABRAL		FACILITY TYPE:	740
ADDRESS:	851 4TH STREET		TELEPHONE:	(213) 478-0800
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	44	CENSUS: 21	DATE:	01/04/2022
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Evacita Bata-House Manager		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident requires a higher level of care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced subsequent complaint investigation at the facility listed above. LPA spoke with house manager Eva Bata via telephone call prior to entering the facility to conduct risk assessment questionnaire and was informed that facility has no COVID cases nor do any of the clients have symptoms. LPA arrived at facility and was greeted by staff Eva Bata. LPA explained the purposed of the visit was to investigate the allegation listed above and was granted access to the facility.

The investigation consisted of the following:
On 12/28/2021 LPA Cifuentes conducted a tour of facility grounds, reviewed facility files and requested and received the following documents: staff and client rosters and other documents pertinent to the investigation. On 1/4/2022 LPA Cifuentes interviewed residents 1-resident 7 (R1-R7) and staff 1-staff4 (S1-S4) regarding the allegation

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: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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 2

Control Number 11-AS-20211221103200

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: 01/04/2022

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
26
27
28
29
30
31
32

Regarding the allegation: Resident requires a higher level of care

The investigation revealed the following:

The complainant alleges resident #1 (R1) requires a higher level of care as they have distressed outbursts throughout the day and night. LPA spoke to House Manager Evacita Bata on 12/28/2021 who stated that R1 does have verbal outbursts during the day and night which they believe are due to residents’ diagnosis. Staff regularly went to R1’s room to check on them and see why they were having an outburst and R1 responded that they were fine, they just felt like shouting. Per House Manager, R1 moved to a new facility on 12/27/2021. LPA was able to confirm move to new facility and attempted to speak to R1, but due to diagnosis, LPA was unable to complete interview with R1. LPA reviewed facility records which show that R1 is able to bathe, dress, use toilet and dress themselves on their own and is independently ambulatory. LPA spoke with facility residents R2 -R7 regarding allegation. LPA asked residents if they believed facility had any residents who required a higher level of care and 5 out of 6 residents stated no. All 6 residents interviewed stated they did not need a higher level of care. LPA Cifuentes interviewed staff regarding allegation. All four staff stated they did not believe facility had any residents that needed a higher level of care. All four staff also indicated an awareness of clients diagnosis and their needs.

Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found no evidence to support the allegation: “Resident requires a higher level of care”.

Although the allegations may have happened or are 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 Evacita Bata and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2