198320301-7-22-2022-11-AS-SCIS-CGKUBN-20220722152636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320301
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:29:18 PM

Document Has Been Signed on 07/22/2022 03:29 PM - It Cannot Be Edited

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 MANOR		FACILITY NUMBER:	198320301
ADMINISTRATOR:	ALCARAZ, MONA M		FACILITY TYPE:	740
ADDRESS:	3425 MCLAUGHLIN AVENUE		TELEPHONE:	(213) 478-0460
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	27	CENSUS: 23	DATE:	07/22/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Mona Alcaraz-Administrator		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/22/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes and Perry Scott conducted an announced inspection to the above facility for purpose of a change of ownership pre-licensing evaluation. An application was submitted to Community Care Licensing Department(CCLD) on 04/23/2022, for a Change of Ownership for a Residential Care for the Elderly. The requested capacity is for 27 clients,22 non-ambulatory, 5 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Structure: Facility has 19 resident bedrooms, 17 client bathrooms, 2 living room/ lounge areas, 2 dining rooms and kitchen. Facility is two stories. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded front yard with a covered patio, tables and chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: LPA observed 19 resident bedrooms, 5 bedrooms are for bedridden and 14 bedrooms are for non-ambulatory. Bedrooms 3a/b, 3c/d and 11a/b, 11c/d have two beds, two chairs, nightstands, overhead lighting, closet and two dressers with several drawers. Bedrooms 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. overrhead lighting, and dressers with several drawers. Most drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Bathroom: Facility has 15 client bathrooms and 2 half baths. Bathrooms1-16 have working toilets, wash basins and showers. There are grab rails next to both the toilets and the showers as well as nonskid mats in showers. LPA observed adequate lighting in hallway leading to bathrooms. Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

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 MANOR	FACILITY NUMBER: 198320301
	VISIT DATE: 07/22/2022

NARRATIVE

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Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene supplies stored in a first floor cupboard..

Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline which was called by LPA and is operational. Emergency Disaster Plan posted & readily available for review on the wall. Three fully charged fire extinguisher were found, one in kitchen and one in downstairs hallway and one in upstairs hallway.

Toxins: Toxins locked/stored in hall cupboard and under kitchen sink.

Water temperature: Water temperature in kitchen and bathrooms measured between 98.3F to 112.5F.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in kitchen drawers. Food supply was adequate and stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: Twenty-four (24) smoke detectors are hardwired and interconnected. 2 carbon monoxide detectors were fond, one on each floor. They were tested and are fully operational.

Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage.

Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients.

Clients & Staff Files: Applicant will not be handling cash resources of clients. Records of staff and clients are stored in cabinets at staff desk.

Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 MANOR	FACILITY NUMBER: 198320301
	VISIT DATE: 07/22/2022

NARRATIVE

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Reading Material, Games, Equipment & Materials: The facility has an activity calendar and provides puzzles other games and papercrafts as well as ball toss and Tai Chi.

Doors have auditory devices to monitor exits.

Pool/Jacuzzi & Pets: LPA's did not observe any pets or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 6/17/2022 for 5 bedridden client and 22 non-ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: Conducted at the Pre-Licensing visit, on 7/22/2022 at Bentley Manor, information provided about how to operate the facility within substantial compliance.

The following corrections need to be completed before licensure:
-Only 26 beds were found and requested capacity is 27.
-Water temperature in 14 of the bathrooms is under 105F
-No locks on kitchen cabinets or drawers for sharps or toxins, toxins found in cabinet and knives in drawer.
-several rooms are in need of repairs such as new screens in windows, small holes in bathroom wall, overhead lights not working.
-Room 3 has insufficient storage space.
-Pests where found in kitchen and two of the residents rooms
-Outside activity area is not properly enclosed with self-closing latches

An exit interview was conducted, and a printed copy of this report was given to the applicant to the applicant. Accordingly, LPA Stephanie Cifuentes will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022

LIC809 (FAS) - (06/04)

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