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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 06/20/2022
Date Signed: 06/20/2022 10:24:05 AM


Document Has Been Signed on 06/20/2022 10:24 AM - It Cannot Be Edited

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: 27DATE:
06/20/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Divine Diaz - StaffTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management visit to the facility Bentley Suites by Serenity Care Health. LPA Cifuentes spoke to staff Divine DIaz and was told facility has no active Covid-19 cases nor do any of the residents have any signs or symptoms. LPA explained the reason for the visit is to follow up on citation issued on September 24, 2021 and was given permission to enter.

LPA Cifuentes was provided a copy of liability insurance for Serenity Care Health Corporation DBA Bentley Suites. The copy of the document provided to LPA shows coverage is 1 million per occurrence and 3 million aggregate and has the same policy number as another facility under Serenity Care Health Corporation. As of today's visit, no changes have been made to the liability insurance coverage provided to LPA Cifuentes

The facility has failed to comply with the POC that was issued on 09/24/2021. Additional citations are being issued under regulation 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS. 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.

Civil Penalties assessed and an exit interview was conducted. Printed copy of report and appeal right were provided to staff Divine Diaz.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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