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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320301
Report Date: 08/24/2023
Date Signed: 08/24/2023 07:56:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/12/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221212123347
FACILITY NAME:BENTLEY MANORFACILITY NUMBER:
198320301
ADMINISTRATOR:ALCARAZ, MONA MFACILITY TYPE:
740
ADDRESS:3425 MCLAUGHLIN AVENUETELEPHONE:
(213) 478-0460
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:27CENSUS: 26DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Mona AlcarazTIME COMPLETED:
10:41 AM
ALLEGATION(S):
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Licensee had liability insurance that did not include required coverage for resident’s injuries.
INVESTIGATION FINDINGS:
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***This amended report supersedes the report dated 5/17/2023. This report is being created to remove substantiated allegation “The Licensee has no current liability insurance” to unsubstantiated. All other complaint report aspects remain in effect. This unannounced subsequent complaint inspection is being conducted by Licensing Program Analysts (LPAs) Ernand Dabuet and Regina Cloyd for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPAs met with facility administrator Mona Alcaraz and explained the reason for today’s inspection.

There was concern that the Licensee representative had liability insurance that did not include the required coverage for resident’s injuries, and that the Licensee representative has no current liability insurance.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
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
Control Number 11-AS-20221212123347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY MANOR
FACILITY NUMBER: 198320301
VISIT DATE: 08/24/2023
NARRATIVE
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On 12/13/2022, LPA Dabuet conducted the initial 10-day complaint investigation and conducted interviews from 9:35 a.m. to 3:08 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Facility staff stated that this facility had liability insurance with an effective date of 08/26/2022. Further investigation was required.

Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, Licensee had liability insurance that did not include required coverage for resident’s injuries. As a result, the above-mentioned allegation is being substantiated. Please see LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.



An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20221212123347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY MANOR
FACILITY NUMBER: 198320301
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2023
Section Cited
HSC
1569.605
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HSC 1569.605 –Liability insurance… all residential care facilities for the elderly … 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.
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Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date (08/25/23).
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This requirement was not met as evidenced by: Based on liability insurance records reviewed, interviews conducted with Administrator and relevant witnesses, it was determined that the licensee did not have required liability insurance coverage for 08/26/2022 to 12/06/22 which poses an immediate safety 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
12/12/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221212123347

FACILITY NAME:BENTLEY MANORFACILITY NUMBER:
198320301
ADMINISTRATOR:ALCARAZ, MONA MFACILITY TYPE:
740
ADDRESS:3425 MCLAUGHLIN AVENUETELEPHONE:
(213) 478-0460
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:27CENSUS: 26DATE:
08/24/2023
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Mona AlcarazTIME COMPLETED:
10:41 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee misrepresented to the Department that they have liability insurance.
The Licensee has no current liability insurance.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***This amended report supersedes the report dated 5/17/2023. This report is being created to add allegation “The Licensee has no current liability insurance” from substantiated to unsubstantiated. All other complaint report aspects remain in effect. This unannounced subsequent complaint inspection is being conducted by Licensing Program Analysts (LPAs) Ernand Dabuet and Regina Cloyd for the purpose of delivering findings for the investigation into the above identified complaint allegations. The LPAs met with Mona Alcaraz facility and explained the reason for today’s inspection.

There was concern that the Licensee representative misrepresented to the Department that they had liability insurance. On 12/13/2022, LPA Dabuet conducted the initial 10-day complaint investigation and conducted interviews from 9:35 a.m. to 3:08 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records.

Evaluation Report continues LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20221212123347
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY MANOR
FACILITY NUMBER: 198320301
VISIT DATE: 08/24/2023
NARRATIVE
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Interviews conducted with facility staff and witnesses revealed that facility was actively working with multiple insurance agencies to finalize the policy to comply with Title 22 Regulations.

Based on review of the policies submitted to the Department between 08/26/2022 and 12/06/2022 there is insufficient information to support the allegations mentioned above.

An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5