198320301-12-13-2022-11-AS-EDAT-CM3VAW-20221213151638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320301
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:16:59 PM

Document Has Been Signed on 12/13/2022 03:16 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: 25	DATE:	12/13/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Sheila Auingan		TIME COMPLETED:	03:39 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 12/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced post licensing visit using the CARE Inspection Tool. LPA met with assistant administrator Sheila Auingan and explained the purpose of today’s visit. The facility is licensed to operate for (27) elderly non-ambulatory adults of which (5) may be bedridden. The facility is approved for (8) hospice residents. Currently, there are (3) hospice 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. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was tested for rooms: #5 112.9 F; #4 114.6 F; #3 109.6 F; #2 105.0 F; #11 115.0 F, and #17 117.6 F A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, 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. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. The facility conducted a Fire/Safety Drill on 11/01/22. A working landline telephone remains available. The facility maintains a PRN Medication Log. Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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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Document is an Amendment of Original Document on 08/24/2023 11:58 AM

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87355(c)(1)(C)

87355(c)(1)(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: (1) A signed Criminal Background Clearance Transfer Request, LIC 9182. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation)(record review), the licensee did not comply with the section cited above. LPA identified staff #2-#10 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/14/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. *A CIVIL PENALTY IS BEING ISSUED TODAY* POC due: 12/14/22

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

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: 12/13/2022

NARRATIVE

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DEFICIENCIES:
Based on record reviews, LPA identified staff #2 through #10 (S2-S10) did not have a Criminal Clearance Background Clearance Transfer for all (9) employees and were not associated at this facility. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited.

Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

IMMEDIATE CIVIL PENALTY

Deficiency are issued and an exit interview is conducted with Sheila Auingan. A copy of this report, appeal rights, and civil penalty were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 12/13/2022 03:17 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87405(b)(2)

87405(b)(2) Administrator-Qualifications and Duties. (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record reviews the administrator failed to adhere to Title 22 regulations, resulting to multiple citations, This violation poses a potential health and safety to residents in care.
	POC Due Date: 12/27/2022
	Plan of Correction
1 2 3 4	The licensee/admnistrator will create a plan to ensure that the administrator performs knowledge of and conform to applicable laws, rules and regulations. A written statement from licensee that reviewed 87405 proof of correction sent by fax 323-981.1781 to El Segundo Regional office by 12/27/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022

LIC809 (FAS) - (06/04)

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