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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 12/09/2024
Date Signed: 04/09/2025 11:27:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2024 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241202162753
FACILITY NAME:BENTLEY SUITESFACILITY NUMBER:
198320302
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0460
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 38DATE:
12/09/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Muriel Cabacungan/Assistant AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not safeguarding resident's belongings .
Staff mismanaged resident's medication.
INVESTIGATION FINDINGS:
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On 4/9/25, at approximately 10:10 AM Licensing Program Analyst-PA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit.

On 12/9/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Resident’s interviews (R#1-R#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Client/Resident Personal Property and Valuables or LIC 621.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 7
Control Number 11-AS-20241202162753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 12/09/2024
NARRATIVE
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Investigation Revealed the Following:

Allegation: Allegations: Staff are not safeguarding resident's belongings.

The details of the complaint alleged that facility staff are not safeguarding residents’ belongings.



During the record review, LPA Iniguez reviewed the (R#1-R#4) inventory. LPA observed that the facility did not document residents’ personal belongings on the list and does not have them sign the form upon admission.

During an interview with (R#1-R#4), (4) out of (4) stated that the facility did not make an inventory list of their personal belongings upon admission.

Allegation: Staff mismanaged resident's medication

On April 9, 2025, at approximately 10:30 AM, during a records review conducted on February 11, 2025, the department received new information indicating that (S#2) reported (R#1) is not taking Metoprolol and Xarelto. (S#2) also stated they are unable to refill these medications, which is why (R#1) does not have them and is not taking them. Additionally, LPA Iniguez reviewed the facility’s Plan of Operation regarding medication policies and procedures. It states, "This facility will assist residents with their medications, provide them with their prescribed medications, and reorder them when necessary."


During this investigation, LPA found sufficient evidence to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

An exit interview was conducted, and a copy of the Complaint Report was given to Muriel Cabacungan/ Assistant Administrator

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20241202162753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2024
Section Cited
HSC
1569.153(d)
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1569.153 Theft and loss program; standards, property inventories and surrender of personal effects; secured areas (d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident's behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident's representative, and dated.
This requirement was not met as evidence by:
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Licensee will ensure a list of personal belongings is create upon admission of resident. As plan of correction, licensee will re-do personal belongings of existing residents and new ones. A copy of the list will be sent to LPA via email before POC due date.
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Based on a review of records and interviews of (R#1-R#4), the facility staff failed to ensure residents personal belongings list was not created upon their admissions

This poses a potential health and safety risk to all residents in care.
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Type B
04/22/2025
Section Cited
CCR
87208(a)
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87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49.
This requirement was not met as evidence by:
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Licensee will adhere to Title 22 at all times. Licensee will submitt plan of correction to LPA Iniguez before POC due date.
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Based on a review of records from new proof submitted to the department and the facility plan of operations, the facility staff failed to refill (R#1) medications. This poses a potential health and safety risk to all 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2024 and conducted by Evaluator Alfonso Iniguez
COMPLAINT CONTROL NUMBER: 11-AS-20241202162753

FACILITY NAME:BENTLEY SUITESFACILITY NUMBER:
198320302
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0460
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 38DATE:
12/09/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Muriel Cabacungan/Assistant AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Licensee does not ensure that staff have required medication training.
Staff do not ensure that facility is clean and sanitary.
INVESTIGATION FINDINGS:
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On 4/9/25, at approximately 10:10 AM Licensing Program Analyst-PA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit.

On 12/9/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Muriel Cabacungan/Assistant Administrator. LPA Iniguez explained the purpose of this visit.
Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Staff Interviews (S#1-S#3) and Resident’s interviews (R#1-R#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#4) Identification and Emergency Information, (R#1-R#4) Physicians Report for Residential Care Facilities for the Elderly , copies of (R#1-R#4) Centrally Store Medication and Destruction Record or LIC 622.

Evaluation Report continues LIC 9099-C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 7
Control Number 11-AS-20241202162753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 12/09/2024
NARRATIVE
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Amended document: allegation of staff mismanage resident's medications findings changed from unsubstantiated to substantiated. See amended LIC 9099 for more details.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20241202162753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 12/09/2024
NARRATIVE
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Allegation: Allegations: Licensee does not ensure that staff have required medication training.

The details of the complaint alleged that facility staff is not trained on how to manage residents’ medications.



During the records review, LPA Iniguez reviewed facility staff medication training; a pharmacy provides the training, and it is 8 hours long. The training includes roles and responsibilities, terminology, types of medication, basic rules and precautions of medication assistance, medication forms, procedures for assisting with self-administration, medication documentation, storage, security and documentation, ordering, and the receipt of medications and side effects. The training is provided every year to most of the facility staff.

During an interview with the administrator (A#1), she stated that most of the staff members are trained on how to manage and dispense medications and are trained every year.

During interviews with residents (R#1-R#4), (3) out of (4) stated that they feel the facility is well-trained regarding medication administration.

During interviews with staff (S#1-S#3), (3) out of (3) stated that they are trained regarding medication administration and get trained every year.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20241202162753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 12/09/2024
NARRATIVE
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Allegation: Allegations: Staff do not ensure that facility is clean and sanitary.

The details of the complaint alleged that facility staff do not ensure facility is clean and sanitary.



During a Health and Safety check of the facility, LPA Iniguez randomly inspected three residents’ rooms, kitchens, and common areas; LPA observed that the facility was clean and sanitary.

During an Interview with the Administrator (A#1), she stated that the facility is clean and sanitary.

During interviews with residents (R#1-R#4), (4) out of (4) stated that the facility is clean and sanitary.

During interviews with staff (S#1-S#3), (3) out (3) stated that the facility is clean and sanitary.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although 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.


An exit interview was conducted, and a copy of the Complaint Report was given to Muriel Cabacungan/ Assistant Administrator

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7