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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 04/03/2025
Date Signed: 04/03/2025 02:41:36 PM

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
03/25/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250325135422
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: 36DATE:
04/03/2025
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Muriel Cabacungan, Assistant AdministratorTIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Staff did not provide copies of resident's file to authorized representative
INVESTIGATION FINDINGS:
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On 04/03/25, Licensing Program Analyst (LPA) Mario Leon conducted an initial visit to gather information regarding the above allegation. LPA met with staff one, Muriel Cabacungan (S1) Assistant Administrator, and the purpose of the visit was explained. LPA was granted entry to the facility.
Investigation consisted of the following: On 04/03/25 LPA requested Resident Roster (dated 03/10/25), staff roster (dated 02/18/25) and Medication list for Resident one (R1), centrally stored medication and destruction record between the dates of 09/01/24 through 12/01/24, Physicians Report for R1, and Admissions Agreement for R1. LPA interviewed three (3) residents (R2-R4), three (3) staff (S1-S3) and one witness (W1). LPA conducted a physical tour of the facility and reviewed paperwork for R1. R1 has been discharged on 12/01/24, LPA was not able to interview R1. Furthermore, staff three (S3) Belen Taico Administrator, is currently on leave. LPA was not able to interview S3.


Report continues, please see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 3
Control Number 11-AS-20250325135422
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: 04/03/2025
NARRATIVE
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Investigation revealed the following:

Regarding the Allegation, "Staff did not provide copies of resident's file to authorized representative". It has been alleged that on March fifth of the year 2025 (03/05/25) a formal letter was dispatched to Bentley Suites requesting photocopies of all documents pertinent to their client, R1, and that the authorized representative (AR) had not received any response.

On 03/28/25 LPA conducted record review of communications from the AR of R1 to the facility. The communications record were listed as follows: at least four (4) electronic communication attempts (e-mail) from AR to the facility between the dates of 03/05/25 - 03/25/25. On 04/03/25 between 09:45AM and 10:45AM, LPA interviewed three (3) residents (R2-R4). R1 was not available for LPA interview. All three (3) residents (R2-R4) disagree with the allegation. On 04/03/25 between 11:00AM and 12:40PM, LPA interviewed two (2) staff (S1-S2). Both interviewed staff (S1-S2) stated that one witness (W1) has received all documentation of R1, as requested, and that W1 has signed R1's emergency ID as reception of documentation of R1 (dates unknown). S1 and S2 have confirmed they had not received electronic messaging from R1's authorized representative (AR). Staff three (S3) was not available for LPA interview. On 04/03/25 between 12:57PM and 1:07PM, LPA interviewed one witness (W1). W1 has stated that they had only received a paper clipped stack of paperwork pertaining to R1, for W1 to bring to R1's new care facility and that R1's AR had not received any response from the facility.

Based on record reviews and interviews conducted, the preponderance of evidence standard has been met.

Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC9099-D.

One deficiency has been cited, see LIC9099-D.

An exit interview was held with staff one, Muriel Cabacungan (S1). A copy of this report, the deficiency cited, and facilities' appeal rights have been provided to Muriel Cabacungan (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250325135422
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: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2025
Section Cited
CCR
87506(c)(1)
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87506 - Resident Records
(c) All information and records...shall be confidential.(1)The licensee shall be responsible for...inactive records...
confidentiality of their contents. The licensee..shall make available to...designated representative.
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The licensee, S2, has agreed that the facility will forward all records of R1 to R1's authorized representative (AR). S2 has agreed that the facility will also carbon copy (CC) to mario.leon@dss.ca.gov on or prior to the POC due date which is 04/07/25.
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This has not been met as evidenced by:
The licensee failed to produce any response to a resident's authorized representative (AR) between the dates of 03/05/25-04/02/25.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3