198320301-8-11-2023-11-AS-AINZ-CULQGZ-20230811121021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320301
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:10:25 PM

Document Has Been Signed on 08/11/2023 12:10 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 26	DATE:	08/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Mona Alcaraz-Administrator		TIME COMPLETED:	12:00 PM

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On 8/11/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Mona Alcaraz/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (27) non-ambulatory elderly adults ages 60 and above of which (5) may be bed ridden. Approved hospice waiver for (8) on rooms: 3#A, 3B, #C, 3D, 4A, and 6 are cleared for bedridden. Currently the facility has (26) residents.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (17) resident's rooms with a bathroom in each room, a living area, a dining area, a kitchen, and an outside patio area with umbrellas.

LPA Iniguez toured the physical plant with director. There were no bodies of water or obstructions on the premises. A total of (6) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 108.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY MANOR	FACILITY NUMBER: 198320301
	VISIT DATE: 08/11/2023

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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. The last Fire/Disaster Drills were conducted on 07/10/23. Annual fire clearance performed 7/25/23 and Fire Kitchen inspection conducted on 7/25/23. Working landline phones are available on-site.

A review of (4) residents' service files (R1-R4) and (4) staff personnel files (S1-S4) and Centrally Stored Medication Destruction Record (CSMDR) were maintained in order. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings. All mandated inspection control posters were posted throughout the facility.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted and a copy of the Facility Evaluation Report was provided to Mona Alcaraz/Administrator) .

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC809 (FAS) - (06/04)

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