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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 08/19/2022
Date Signed: 08/19/2022 02:20:30 PM

Substantiated


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
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/09/2022 and conducted by Evaluator Troy Agard
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220809092109
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: 23DATE:
08/19/2022
UNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Divine Grace Diaz, CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocols.
Facility does not maintain accurate resident records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Troy Agard conducted a subsequent complaint investigation for the allegations listed above. LPA Agard explained the purpose of this visit is to gather information regarding the complaint allegations.

On 08/12/2022, the investigation consisted of the following: LPA Agard conducted a tour of the facility grounds. The facility is a two-story structure located in a residential neighborhood. It consists of the following: twenty-two (22) resident rooms with attached baths, lounge, outdoor patio, dining area, kitchen, pantry and laundry room. LPA conducted an initial 10-day visit and met with Divine Grace Diaz, Caregiver. LPA completed interviews and requested copies of the following records: 1) A copy of the staff roster, 2) a copy of the resident roster with their date of birth, 3) Covid screening tool, 4) visitors sign-in sheets, 5) Admissions agreement for R1. Some documents were received during visit. Remaining documents are due 08/19/2022.

Cont. on 9099C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
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 4
Control Number 11-AS-20220809092109
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
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 08/19/2022
NARRATIVE
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On 08/19/2022, LPA conducted additional interviews and delivered findings.

The investigation revealed the following: Regarding the allegation: Facility is not following COVID-19 protocols. “It’s being alleged staff did not do any type of screening per COVID19 protocol prior to a visitor entering into the facility or after entering. No one questioned visitor nor was their temperature taken.” On 08/12 and 08/19/2022 LPA interviewed 4 out of a total of 23 residents. 2 out of 4 residents could not confirmed the allegation to be true. 2 confirmed the allegation to be false. R1 states, “I think they are following covid protocol, I’m not sure.” R2 states, “yes, visitors are all screened for covid. They are asked questions and required to wear a mask.” R3 states, the facility does follow covid protocol to my knowledge. I don’t have anyone that visits but they do have people sign in and out.” R4 states, “I don’t know if they require people to sign in. My friends come to visit me, and they don’t have to sign in. I’ve never really seen this book before.”

During interviews with staff, LPA interviewed 2 out of 10 in total. 1 out of 2 confirmed the allegation to be true. On 08/12/ 2022 S1 states, “at first when someone comes in, we ask for their vaccination card, get their body temperature and have them sign in. We are currently looking for the logbook that’s why you weren’t able to sign in. One of the residents keeps taking it. One of the ombudsmen told me that one of the staff didn’t screen a visitor for covid and I apologized about that.”

The investigation revealed the following: Regarding the allegation: Facility does not maintain accurate resident records. “It’s being alleged the facility roster was received incomplete or not updated with all resident’s information.” On 08/12 and 08/19/2022 LPA interviewed 4 out of a total of 23 residents. 0 out of 4 residents could not confirmed the allegation to be true. All residents unanimously state they either did not know or could not be sure. R1-R3 states, “I’m not sure if they maintain accurate resident records.” R4 states, I don’t know.”

During interviews with staff, LPA interviewed 2 out of 10 in total. Both staff deny the allegation but admits that an updated facility roster is not on the premises. On 08/12/2022 S1 states, “we have a roster it’s just not updated, and our manager is out. They sent us over a new one but it’s not printing the names. R1 moved in in June of 2022. They have been here for almost two months.” S2 states, “we have an updated roster it’s just not printing.”
Cont on 9099C
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20220809092109
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
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
VISIT DATE: 08/19/2022
NARRATIVE
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On 08/12/2022, LPA Agard observed the following at time of visit: on 08/12/2022, LPA was not properly screened for covid. Temperature was checked but LPA did not sign in nor was he screened for covid symptoms. LPA observed the facility screening tools and sign in sheets. Most of the signatures were missing screening information. LPA was given a handwritten list of names of residents that had been updated at the time of visit. A proper facility roster was not observed onsite. LPA reviewed a section of R1’s admissions agreement which shows resident moved to the facility in March of 2022.

Based on LPA’s observation, interviews conducted, and record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division (6) and chapter (1) are being cited on the attached LIC 9099D.

An exit interview was conducted. Plans of corrections were developed. A copy of this report and appeal rights were given.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20220809092109
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
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES BY SERENITY CARE HEALTH
FACILITY NUMBER: 197609123
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by: Facility failed to ensure visitors were being
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Facility Administrator will review PIN 22-07 ASC and facility mitigation plan with all facility staff and have them sign off that they have read and understand. Sign in sheet and training material must be sent to LPA via email or fax by POC due date. 09/02/2022
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screened for covid related symptoms. Per PIN 22-07 ASC dated 02/07/2022. Requirements for Licensee for any visitors regardless of vaccination status must have a designated facility staff member to conduct initial screening for covid symptoms. LPA was not screened during visit on 08/12/2022. This presents a health and safety concern to residents in care.
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Type B
09/02/2022
Section Cited
CCR
87506(a)
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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by
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Facility Administrator will review section 87506 in title 22 and provide LPA with a written confirmation that they have read the section in its entirety and understand. The statement of confirmation must be sent to LPA via email or fax by POC due date. 09/02/2022
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Record review. A proper updated facility roster was not observed onsite. This presents a health and safety concern to residents 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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Troy AgardTELEPHONE: (323) 400-7109
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4