198320301-5-2-2023-11-AS-RORN-CRXPNR-20230518112818

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320301
Report Date: 05/02/2023
Date Signed: 05/02/2023 01:08:56 PM

Unsubstantiated

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
02/22/2023 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230222081854

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: 20	DATE:	05/02/2023
		UNANNOUNCED	TIME BEGAN:	12:13 PM
MET WITH:	Administrator ALCARAZ, MONA		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Resident sustained injury due to staff neglect
Staff did not notify resident's authorized representatives of incident

INVESTIGATION FINDINGS:

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On 5/02/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced subsequent complaint visit at the facility listed above. LPA arrived at facility and was greeted by Administrator ALCARAZ, MONA. LPA explained the purposed of the visit is to deliver findings on the allegations listed above.
The investigation consisted of the following:
LPA observed facility, as well as common areas of the facility. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair., LPA requested pertinent documents pertaining to the investigation. The following documents were gathered: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, hospice records, hospital records for R1.

On 03/01/2023 LPA Randle interviewed residents (R1-R6). LPA requested, received, and reviewed the following information: entire file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. LPA interviewed staff (S2-S6) regarding allegations listed above.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

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 4

Control Number 11-AS-20230222081854

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: 05/02/2023

NARRATIVE

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Investigation Revealed the following.

Allegation: Resident sustained injury due to staff neglect

Regarding Allegation #1: Resident sustained injury due to staff neglect.

LPA Randle interviewed collateral witness 1(CW1) for complaint. CW1 states that R1 is in hospice care for end stage cancer. CW1 states that hospice staff had seen R1 on 02/14/2023 and there was no injury to the face of R1. CW1 states that collateral witness 2 (CW2) had called CW1 and alleged that facility staff had slapped R1 face. CW1 states that CW1 interviewed R1 who told CW1 that staff had not slapped R1 face and R1 had scratched R1 own face. CW1 states that the injury to R1 face does not look like a hand slap and more like a fingernail scratch. LPA Randle interviewed CW2-CW3 for complaint. CW2-CW3 stated that R1 told them at different times that S1 had slapped R1 face because R1 urinated in R1’s bed. CW2-CW3 stated that R1 has health issues and gets confused easily and makes up stories. LPA Randle received and reviewed color pictures of facial injury to R1 face from CW2. Reviewed color pictures of R1 face with CW1, the skin tear does not appear to come from a slap to the face with open hand and appears more in line with a fingernail scratch due to the age of R1 skin per CW1. LPA Randle interviewed CW4 for complaint. CW4 states that R1 has cognitive issues and makes up stories and gets confused. CW4 states that CW2 also makes up stories believed. LPA Randle interviewed R1 for complaint. R1 states that R1 bumped a wall in R1 room and injured R1 face cheek. R1 states that R1 then scratched R1 face opening the tear. R1 states that no staff member attacked R1 or slapped R1 face.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230222081854

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: 05/02/2023

NARRATIVE

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LPA Randle interviewed R2-R6 for complaint. R2-R6 state that residents have never heard of a staff member attacking another resident and that R1 scratched R1 face, and this is how R1 injured R1 face. LPA Randle interviewed S1 for complaint. S1 states that S1 has never attacked or put S1 hands on R1 and R1 scratched R1 face then picked at scar and this is how R1 face was injured. S1 states that no resident or staff ever attacked R1. LPA Randle interviewed S2-S6 for complaint. S2-S6 state that no staff member ever put their hands or slapped R1 face and R1 scratched R1 face, and this is how R1 face was injured. S2-S6 state that they give the best service possible to all residents. LPA Randle reviewed facility file to include needs and service, physician report, hospice records, pre-placement for R1. Records suggest that R1 has cognitive impairment issues, gets confused and makes up stories.

Based on information gathered, the department did not find sufficient evidence to support allegation " Staff physically abused resident in care.

Allegation: Staff did not notify resident's authorized representatives of incident

Regarding Allegation #2: Staff did not notify resident's authorized representatives of incident.

LPA interviewed Administrator ALCARAZ, MONA (S1) denied the allegation. Administrator S1 added that R1’s has no designated POA and R1’s legal representative per R1’s physician report is her husband.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230222081854

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: 05/02/2023

NARRATIVE

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S1 states that CW4 visits often usually most days. S1 states that S1 keeps CW4 informed of any issues or changes in condition. LPA interviewed CW4, CW4 stated that S1 keeps him informed of resident R1 condition and that he loved the facility, and the facility cares for R1’s needs. LPA interviewed residents (R2-R7) regarding the allegation Staff did not notify resident's authorized representatives of incidents. Residents interviewed all stated (R2-R7) they had no problem with staff communicating their change of condition or incidents to their authorized representatives. LPA interviewed staff (S2-S6) regarding allegation all stated there were no delays in communicating to authorized representatives of changes to residents’ condition or incidents.

Based on information gathered, the department did not find sufficient evidence to support allegation Staff did not notify resident's authorized representatives of incident

The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found No evidence to support the allegations:

Resident sustained injury due to staff neglect

Staff did not notify resident's authorized representatives of incidentAlthough the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. An exit interview was conducted with Administrator ALCARAZ, MONA and a hard copy was provided.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 213-1116
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2023

LIC9099 (FAS) - (06/04)

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