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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:52:38 PM


Document Has Been Signed on 08/03/2022 04:52 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:
08/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:05 PM
MET WITH:Divine Diaz-StaffTIME COMPLETED:
05:00 PM
NARRATIVE
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On 08/3/2022, Licensing Program Analysts (LPA) Stephanie Cifuentes conducted a case management visit at this facility. LPA met with staff Divine Diaz and explained the purpose of today’s visit is to issue a citation.

During pre-licensing inspection follow-up visit for change of ownership on 8/3/2022 LPA Cifuentes observed a Writ of Execution for resident 1 (R1), with an attached notice to vacate. LPA reviewed facility records and did not find a copy of a 30 day eviction for R1. LPA asked staff for a copy and they were unable to provide it. LPA noted that a copy of eviction notice was not sent to Community care licensing within 5 days.

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 Divine Diaz.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 2


Document Has Been Signed on 08/03/2022 04:52 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2022
Section Cited

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Eviction Procedures
The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
This requirement is not met as evidence by:
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Based on record reviews the facility did not provide 30 day written notice to resident. This violation poses a potential health risks to residents in care.
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Type B
08/17/2022
Section Cited

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Eviction Procedures
A written report of any eviction shall be sent to the licensing agency within five (5) days.
This requirement is not met as evidenced by:
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Based on records review, facility failed to properly inform CCLD of 30 day notice issued for resident. This is a potential health and safety risk to resident 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: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2