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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:13:17 AM

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: 22DATE:
08/26/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Eva Bata-House ManagerTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management POC visit to this facility Bentley Suites by Serenity Care Health. LPA Cifuentes arrived and spoke to house manager Evacita Bata. LPA explained the reason for the visit.

On 07/27/2021, LPA Cifuentes conducted a case management visit and cited the facility for failing to provide proof of liability insurance coverage under HEALTH & SAFETY CODE 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.

On 08/26/2021, LPA Cifuentes conducted a Case Management POC follow up visit with the facility to ensure that the requirement has been met and the facility is in compliance.

During the visit, LPA spoke with Administrator Mona Alcarez (via telephone), who advised LPA Cifuentes that the corporate office is still in the process of gaining the liability insurance coverage.

The facility failed to comply with the POC that was issued on 07/27/21 and a new citation is being issued under regulation. 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.

A copy of the report was issued to Manager Eva Bata
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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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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: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited

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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
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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.
This requirement has not been met :Based on observation and interviews conducted the failed to provide proof of liability insurance during the visit.
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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: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021
LIC809 (FAS) - (06/04)
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