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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:02:42 PM

Unsubstantiated


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
08/06/2024 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240806110431
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:
12/11/2024
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Muriel CabacunganTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained an unexplained injury while in care.
INVESTIGATION FINDINGS:
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On 08/12/24, at 9:25am, Licensing Program Analyst (LPA) David Espana conducted an initial complaint visit to the facility and was greeted by Muriel Cabacungan, Assist Administrator. LPA explained the purpose of this visit is to conduct interviews, gather facility files, and render findings in the complaint.

The investigation consisted of the following: An initial complaint visit was completed by LPA David Espana on 08/12/2024. A subsequent visit was completed by LPA Perry Scott on 12/11/2024. The department investigated the allegation mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R4). Additionally, the department obtained the following documents: Resident Roster (Dated: 04/24/2024), Staff Roster (Dated: 07/18/2024), ID Emergency Information (Dated: 11/18/2023 & 11/14/2023), Resident Appraisal (Dated: 11/21/2023) and Pre-admission Appraisal (Dated: 11/01/2023 & 11/15/2023), Incident reports (Dated: 07/31/2024 & 08/05/2024), Admission Agreement (Dated: 11/17/2023), and Physician’s Report (Dated: 07/18/2024) from the facility.

Complaint Investigation Report Continues on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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 2
Control Number 11-AS-20240806110431
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: 12/11/2024
NARRATIVE
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The investigation revealed the following: Allegation- Resident sustained an unexplained injury while in care.

The details of the complaint alleged that the resident (R1) sustained an unexplained bruise on R1s right eye. On 08/12/24 the department interviewed staff (S1-S3). On 12/11/24, from 09:30am-2:00pm, the department interviewed staff (S4) and residents (R1-R4) regarding the allegation. 4 of 4 staff (S1- S4) denied knowing how the Resident sustained an unexplained injury while in care. All staff (S1-S4) stated that they did not see what happened to cause an injury to R1. S1 states that R1 may have fallen out of a rocking chair in R1s room and hit R1s face but are not sure.

S1 also stated that they now have a baby camera in R1s room to monitor the resident, that was authorized by the family, which does not record though. All staff (S1-S4) stated that R1 wanders around a lot and is sundowning. They deny that anyone may have done this to R1 and that R1 may have fallen. They state that R1 has fallen in the past. The department reviewed the Incident Report (Dated: 07/31/2024) that was sent to Community Care Licensing informing the department of the unexplained bruise. The department also reviewed the Physician’s Report (Dated: 07/18/2024) that states that the resident has sundowning behavior and can become confused and disoriented.

The department interviewed residents (R1-R4) about the allegation and 3 of 4 residents that were interviewed denied any knowledge of how the Resident sustained an unexplained injury while in care. The majority (3 of 4) residents interviewed stated that they had no knowledge of how the resident was injured and have not been injured or abused themselves by any staff or resident at the facility.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that the Resident sustained an unexplained injury while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is Unsubstantiated.

No citations were issued for this complaint.

An exit interview was conducted with Muriel Cabacungan, Assist Administrator, and a copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2