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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320301
Report Date: 03/01/2023
Date Signed: 06/10/2023 11:00:05 AM

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
02/24/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20230224093036
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: 20DATE:
03/01/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:ADMINISTRATOR MONA ALCARAZTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff physically abused resident in care.
INVESTIGATION FINDINGS:
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This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/01/2023.

Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Bentley Manor on 03/01/2023 and was greeted by Administrator Mona Alcaraz (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

During this investigation, LPA Calderon interviewed A1, W2-W4, S2-S6, R1-R10. These interviews were conducted on 02/27/2023 and 03/01/2023. On 03/01/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, hospice records, hospital records, incident report for R1.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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 3
Control Number 11-AS-20230224093036
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: 03/01/2023
NARRATIVE
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Regarding Allegation #1: Staff physically abused resident in care.

The investigation revealed the following:

Regarding Allegation #1: Staff physically abused resident in care.

On 03/01/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 “bumped a wall” in R1’s room. R1 states this caused the injury to R1’s face. R1 then scratched R1’s face and this created a tear in the skin. R1 states the injury was not the result of staff physically abusing R1. On 03/01/2023 LPA Calderon interviewed R2-R6 for this complaint and 5 out of 5 residents affirmed they have not heard or witnessed facility staff physically abuse residents. On 03/01/2023 LPA Calderon interviewed A1 who reports R1 scratched R1’s face and this caused an open wound on R1’s face. A1 stated R1 re-injured the scratch when touching the area after it developed a scab. On 03/01/2023 LPA Calderon interviewed S2-S7 for complaint and 6 out of 6 staff members expressed they have not witnessed facility employees physically abuse residents and the cause of R1’s wound was the result of R1 scratching R1’a face.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20230224093036
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: 03/01/2023
NARRATIVE
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Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff physically abused resident in care” is found to be UNSUBSTANTIATED.


An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Mona Alcaraz (A1).
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3