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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609123
Report Date: 09/08/2021
Date Signed: 09/08/2021 11:58:02 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: 23DATE:
09/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Eva Bata-House ManagerTIME COMPLETED:
12:00 PM
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On 9/8/2021, Licensing Program Analysts (LPAs) Stephanie Cifuentes and Jennifer Jones, Licensing Program Manager (LPM) Eva Alvarez, Long term Care Ombudsmen (LTCO) Gilda Nori and Molly Davies conducted an unannounced Case Management Joint visit to the above facility to meet with residents.. LPA met with Evacita Bata-House Manager and explained the purpose of the visit is to meet with Residents and provide copies of Decision and Order as well as Accusation in relation to October 29, 2021 facility closure.

Upon arrival LPA CIfuentes conducted a Health and Safety tour of the facility grounds.

During today’s visit, Resident's were informed of planned closure and provided the Accusation, Decision and Order.

No deficiencies were cited during today's visit.

An exit meeting was held and a copy of the report was given to House Manager Eva Bata



House Manager Evacita Bata Declined to Sign Report.

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SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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