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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609123
Report Date: 07/30/2021
Date Signed: 08/17/2021 07:42:07 AM



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
06/30/2020 and conducted by Evaluator Susan Campos
COMPLAINT CONTROL NUMBER: 11-AS-20200630123139
FACILITY NAME:BENTLEY SUITES BY SERENITY CARE HEALTHFACILITY NUMBER:
197609123
ADMINISTRATOR:MONA ALCARAZFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0800
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 22DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Eva Bata TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff physically rough with residents in care
Staff verbally abusive to resident
INVESTIGATION FINDINGS:
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On 7/30/2021 at 8:24 am, Licensing Program Analyst (LPA)/Susan Campos, initiated a subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA was allowed entry into the facility by Eva Bata, Facility Manager. LPA explained to Ms. Bata the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (4) staff members and (4) residents on 7/30/21. In addition, LPA and Mr. Renel Cabral conducted a virtual inspection on 7/3/20, for health and safety, the facilities’ physical plant, and food supply. The common areas such as office, dining room, kitchen, TV room, and outdoor patio. LPA also reviewed the following documents provided by Bentley Suites Mr. Ronel Cabral, Administrator: staff roster, client roster, staff schedule, facility meal menu for week 6/21/20-6/27/20, 6/28/20-7/4/20, and 7/5/20-4/11/20, and 7/25/21-7/30/21.

Continued on LIC 809C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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 5
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
06/30/2020 and conducted by Evaluator Susan Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200630123139

FACILITY NAME:BENTLEY SUITES BY SERENITY CARE HEALTHFACILITY NUMBER:
197609123
ADMINISTRATOR:MONA ALCARAZFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0800
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 22DATE:
07/30/2021
UNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Eva Bata TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident provided inferior and insufficient amount of food
INVESTIGATION FINDINGS:
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5
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On 7/30/2021 at 8:24 am, Licensing Program Analyst (LPA)/Susan Campos, initiated a subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA was allowed entry into the facility by Eva Bata, Facility Manager. LPA explained to Ms. Bata the purpose of the visit. The investigation consisted of the following: LPA conducted interviews with (4) staff members and (4) residents on 7/30/21. In addition, on 7/30/21, LPA and Mr. Renel Cabral conducted a virtual inspection on 7/3/20, for health and safety, the facilities’ physical plant, and food supply. The common areas such as office, dining room, kitchen, TV room, and outdoor patio. LPA also reviewed the following documents provided by Bentley Suites Mr. Ronel Cabral, Administrator: staff roster, client roster, staff schedule, facility meal menu for week 6/21/20-6/27/20, 6/28/20-7/4/20, and 7/5/20-4/11/20, and 7/25/21-7/31/21.

Continued on LIC 809C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20200630123139
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: 07/30/2021
NARRATIVE
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Investigation

Allegation: Resident provided inferior and insufficient amount of food

The investigation revealed, per LPA interviews, with (4) staff members, and (4) residents from the Bentley Suites facility, and review of facility documents that the facility offers adequate and sufficient amount of food.

In addition, S1 informed LPA, that has not received complaints from residents that they did not receive sufficient amount of food during their meals, and also that the food was inferior. In fact, S1 states that all residents are offered second portions upon request. In addition, residents may ask for something else to be prepared if they do not like the meal offered. The LPA interviewed (4) Bentley Suites staff persons and 4 of the 4 staff members interviewed, informed LPA, that the facility serves a sufficient amount of food to the residents during meal time, and also that during meal time the residents may receive second portions upon request. In addition, 4 of 4 staff persons informed LPA that the kitchen will make resident something else to eat if there are no seconds to offer the residents. Also LPA interviewed 4 residents, and 4 of 4 residents informed LPA that the food quality is good, and also that they receive a sufficient amount of food during their meal. In addition, 4 of the 4 residents informed the LPA that they are offered second servings if they wish.

LPA and Ms. Bata inspected the food inventory in the facility, and the facility has the required 3 day perishable and 7 day non-perishable food.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Resident provided inferior and insufficient amount of food ”.

Although the allegations may have happened or is 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 Eva Bata, Office Manager, and a LIC 9099 hard copy was provided to Eva Bata.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20200630123139
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: 07/30/2021
NARRATIVE
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Allegation: Staff physically rough with residents in care

The investigation revealed, per LPA interviews, with (4) staff members, and (4) clients from the Bentley Suites facility, and review of facility documents that staff physically rough with residents in care.

S1 informed LPA, that is not aware, and has not been reported, by a staff person or resident, that a staff person working in the facility is physically rough with a resident. The LPA interviewed (4) Bentley Suites staff persons and 4 of the 4 staff members interviewed, informed LPA, that they are not aware or have been informed, that a staff person is physically rough with the residents in the facility. Also LPA interviewed 4 residents, and 3 of 4 residents informed LPA that staff are not physically rough while providing care.

On 7/30/21, at 9:50 am, LPA was informed by R2 that S4 is rough when providing care. S4 uses a sharp brush during bathes, that hurts R2, and a razor that pinches R2's face.

Based on information gathered, LPA did find sufficient evidence to support allegation " Staff physically rough with residents in care ”.

Allegation: Staff verbally abusive residents

The Department of Social Services Investigation Branch's Department conducted interviews with Bentley Suites staff members for a complaint investigation, and informed LPA Campos that S5 informed Investigator Peter Zertuchem on 6/29/20 at 3pm, during a video interview, that S5 cursed at R5. Investigator Zertuchem, informed former facility manager Renel Cabral, on 7/1/21 at 11am that S5 had verbally cursed at R5, and Mr. Cabral informed investigator Zertuchem that would speak with R5 in order for it not to happen again.

Based on information gathered, LPA did not find sufficient evidence to support allegation " Staff verbally abusive to resident”.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. A exit interview was conducted with Eva Bata, Office Manager and a hard copy of a LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20200630123139
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: 07/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited
HSC
87468.1(a)(1)
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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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Administrator will provide LPA, per fax, training hours and topics for S4, topic: resident care services, and provide facility staff with in house training program on proper care service for facility residents.

LPA fax number (323) 981-1781.
POC Due Date is 8/13/21.
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Based on interviews, observation, and record review, on 7/30/21, LPA was informed by R2 that S4 is physically rough while providing care which poses a potential health risk to residents in care.
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Type B
08/13/2021
Section Cited
HSC
87468.2(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement is not met as evidenced by:
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Administrator will provide LPA, per fax, training material and facility staff sign in sheet, for an in house training session on staff verbal abuse prevention.

LPA fax number (323) 981-1781.
POC Due Date is 8/13/21
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Based on interviews, observation, and record review , DSS IB Investigator Zertuche was informed by S5, on 6/29/20 that S5 verbally cursed at R5, which posed a potential health risk 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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5