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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320302
Report Date: 11/04/2023
Date Signed: 11/04/2023 05:42:16 PM


Document Has Been Signed on 11/04/2023 05:42 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 SUITESFACILITY NUMBER:
198320302
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0460
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:44CENSUS: 35DATE:
11/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hazel LaguevarraTIME COMPLETED:
03:59 PM
NARRATIVE
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On 11/04/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with care staff Hazel Luguevarra. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to serve (44) non-ambulatory elderly residents of which (4) may be bedridden ages 60 and above. The facility is approved for (15) hospice residents. Currently, the facility has (5) hospice residents. Rooms #1, #3, #4, and #5 are cleared for bedridden residents.

The facility is a two-story structure located in a residential neighborhood. It consists of the following: (22) resident bedrooms. Each room has a bathroom in the room, an activity room, dining room, a kitchen, storage closets, an administrative office, and an open patio area.

LPA toured the physical plant. There were no bodies of water on the premises. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #1, #2, #7 #10, #17, and #19. Bathrooms were operational. A comfortable temperature was maintained in the facility at 72 - 74 degrees F.



LPA observed the facility to be 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 sufficient perishable and non-perishable food was maintained adequately.

Fire extinguishers were fully charged, and smoke detectors and carbon monoxide were operable in each resident's room. The facility has a certificate of liability insurance effective 08/26/23 - 08/26/24. The facility is current on annual license fees.
(Evaluation Report continues LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
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 SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 11/04/2023
NARRATIVE
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The facility maintains for each resident Centrally Stored Medication Destruction Record and PRN Log. 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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#6 (S1-S6) personnel files were in maintained in place. LPA conducted (2) residents and (2) staff interviews.

DEFICIENCIES:
  • During resident file review between 11:30 AM - 12:15 PM, resident #4 is identified as bedridden in room #7 is in a room not cleared for bedridden. - Type A (Civil Penalty)
  • Hot water temperature for rooms #1 & #2 ranged at 161.2-165.9 at 12:34 PM. - Type A
  • Furnishing of bed mattress, wheelchair, and other furniture obstructing passage way adjacent to room #10 at 12:45 PM. - Type A
  • Bathroom baseboards were rusted and filled with mold in room #19 at 12:47 PM. - Type B
  • Open powder bleach found under bathroom sink in room #7 accessible to residents in care at 12:53 PM. Type A
  • Facility has not conducted a quarterly fire drill consistently. Last drill was performed June 2023. - Type B


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Hazel Luguevarra, and a copy of the report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2023 05:42 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 SUITES
FACILITY NUMBER: 198320302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified room #1 & 2 had hot water temperature range at 161.2 -165.9 degree F. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2023
Plan of Correction
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Hot water temperature must meet the Title 22 regulations requirement of not less than 105. degree F and not more than 120 degree F. Licensee will make correction to reduce the water temperature to meet the requirements at all times.
Proof of correction must be sent to LPA Dabuet at: ernand.dabuet@dss.ca.gov no later than 11/05/23.
*Corrected during visit 11/04/23*

Corrected during visit on 11/04/23.
Section Cited
Maintenance and Operation
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2023 05:42 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 SUITES
FACILITY NUMBER: 198320302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Limitations -Capacity and Ambulatory Status
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87204(b)
Limitations -Capacity and Ambulatory Status
(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section. Resident #4 who is bedridden is in a ambulatory room 7A not cleared for bedridden room. The licensee is operating beyond the conditions and limitations specified on the license. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2023
Plan of Correction
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The licensee will need to transfer hospice resident #4 to an approved bedriddent room 1,3, 4 or 5 in order to correct this violation. This violation must be completed by due date 11/05/23. Proof of correction must be sent to ernand.dabuet@dss.ca.gov
*Immediate Civil Penalty*


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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2023 05:42 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 SUITES
FACILITY NUMBER: 198320302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified funiture, mattress, wheelcair and other furnishing supplies obstructing passage way adjacent to room #10. Staff indicated this furnishings have been blocking passage way for several days. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2023
Plan of Correction
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Licensee will remove furnishing obstructing passage way immediately. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov by due date 11/05/23.

*Corrected during visit on 11/04/23*
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation., the licensee did not comply with the section cited above. LPA identified open powder bleach under bathroom sink accessible to dementia residents in care in room #7. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2023
Plan of Correction
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LIcensee will adhere to Title 22 regulations section 87309 and ensure that all toxic, hazardous chemical items are store in locked cabinets and not accessible to residents in care. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov by 11/05/23.
*Corrected during visit on 11/4/23*
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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2023 05:42 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 SUITES
FACILITY NUMBER: 198320302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA identified room #19 bathroom baseboards had rust/mold and need to be replaced. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2023
Plan of Correction
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Licensee will make necessary repairs and replace with new bathroom baseboards. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov by 12/04/23.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified the facility had not conducted a recent quarterly fire drill. The last drill was completed in June 2023. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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Licensee will adhere to H&S regulations 1569.695 and continue to conduct quarterly fire drills. Proof of correction must be sent to LPA at ernand.dabuet@dss.ca.gov by due date 11/18/23.
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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2023
LIC809 (FAS) - (06/04)
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