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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 08/31/2021
Date Signed: 08/31/2021 02:09:50 PM

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:
08/31/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Evacita BataTIME COMPLETED:
02:15 PM
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On 8/31/2021, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management- Legal/Plan of Corrections visit to the above facility regarding deficiencies issued on 8/26/2021. LPA met with Evacita Bata-House Manager and explained the purpose of the visit.

During today’s visit, LPA Cifuentes reviewed facility files. During the visit, LPA Cifuentes requested copies of resident Emergency ID, staff and resident rosters, admission agreements and physicians reports. LPA Cifuentes spoke with Mona Alcaraz via telephone about the liability insurance coverage and was advised that the corporate office is still handling the liability coverage issue.

The facility failed to comply with the POC that was issued on 08/26/21. Additional citations are being issued under regulation. 1569.605 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 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.



Civil Penalties assessed and an exit interview was conducted. “The house manager was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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