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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 07/25/2022
Date Signed: 07/25/2022 05:34:32 PM


Document Has Been Signed on 07/25/2022 05:34 PM - 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:
07/25/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:59 PM
MET WITH:Mona Alcaraz-AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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On 07/25/2022, Licensing Program Analysts (LPA's) Stephanie Cifuentes and Perry Scott conducted a case management visit at this facility. LPA's met with administrator Mona Alcaraz and explained the purpose of today’s visit is to issue a citation.

During pre-licensing inspection on 7/25/2022 for a change of ownership, LPA CIfuentes observed the following deficiencies:

1. Bathrooms as well as kitchen sink had water temperatures ranging from 99.8F to 144F.
2. Bedrooms 3, 28, 15 were shared rooms and were missing the second bed and room 10 had no bed at all.
3. Bedrooms 12, 17, 18, 19, and 21 had no light.
4. Bedrooms 2 and 3 had no smoke detectors, and rooms 1, 12, 14 and 15 had smoke detectors that did not operate.

Deficiencies cited under the California Code Regulations (CCR) Title 22, chapter 6 on attached 809-D.

An exit interview was conducted and a copy of this report and appeal rights were provided to staff Mona Alcaraz.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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 3


Document Has Been Signed on 07/25/2022 05:34 PM - It Cannot Be Edited

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: 07/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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Maintenance and Operation
There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
This requirement is not met as evidenced by:
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During inspection on 7/25/2022, LPA noted that bedrooms 12, 17, 18, 19, and 21 had no light. THis is a potential health and safety risk to residents in care.
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Type B
07/29/2022
Section Cited

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Personal Accommodations and Services
A bed for each resident...Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant...
This requirement is not met as evidenced by:
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During inspection on 7/25/2022, LPA noted that 3, 28, 15 were shared rooms and were missing the second bed and room 10 had no bed at all. This is a potential health and safety risk to clients 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: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/25/2022 05:34 PM - It Cannot Be Edited

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: 07/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2022
Section Cited

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Maintenance and Operation
Faucets used by residents for personal care...shall deliver hot water. Hot water temperature controls shall be maintained... a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degrees C)
This requirement is not met as evidenced by:
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Based on observation, the water temparture for facility bathrooms was between 99.8F to 144F F. This poses an immediate health and safety risk to residents in care.
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Type A
07/26/2022
Section Cited

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Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
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Based on observation Bedrooms 2 and 3 had no smoke detectors, and rooms 1, 12, 14 and 15 had smoke detectors that did not operate.
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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: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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