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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 04/24/2025
Date Signed: 04/24/2025 04:02:22 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/16/2025 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20250416134005
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:
04/24/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Muriel CabacanganTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff refused to provide resident's authorized representative copies of resident's file.
INVESTIGATION FINDINGS:
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On 04/24/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with Assistant Administrator, Muriel Cabacungan, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:
During today’s visit on 04/24/2025, LPA inspected the facility, interviewed Staff S1-S4, interviewed Residents R2 and R3, interviewed resident’s Responsible Party W1-W3, and received documents pertinent to the investigation. LPA received and reviewed the following documents Staff Roster, Resident Roster, Resident Information Sheet (dated 12/28/2022), Admission Agreement (dated 12/29/2022) Admission Record for Culver West Health Center (dated 12/27/2022), Admission Orders (dated 12/27/2022), Physician’s Report (dated 12/27/2022, 08/18/2023, and 08/23/2024), Culver West Health Center Order Summary Report (dated 11/29/2022), and emails between the facility and resident’s representative.
The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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 4
Control Number 11-AS-20250416134005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 04/24/2025
NARRATIVE
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Allegation: Staff refused to provide resident’s authorized representative copies of resident’s files.
The allegation alleges that a written request was submitted on March 5, 2025, and the facility was contacted multiple times with the request, and the documents have not been provided.
During the facility inspection, LPA observed resident file stored in the office. For residents who have moved out or have passed away the files were observed in a locked file cabinet in a second-floor storage room.
During record review, LPA reviewed R1’s Admission Agreement that includes Personal Rights in Privately Operated Residential Care Facilities for the Elderly that states on number 21 that residents have the right “To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies.” Additionally, LPA received copies of emails between the Administrator and R1's Representatives offices indicating Invoice Ledgers for R1 were sent. LPA reviewed a letter dated 03/05/2025, that requests “a copy of all writings related to R1 within your care, custody and control. Copies shall include all “resident records’ for R1.”
During interviews with Staff S1-S4, were asked if resident R1 was provided with documents requested, four (4) out of four (4) stated yes, R1 was provided with the documents from their file when they moved out. Additionally, S1 stated they emailed the Invoice Ledgers for R1 to the requesting person who is a representative for R1.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250416134005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
VISIT DATE: 04/24/2025
NARRATIVE
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During interviews with Residents R2 and R3, were asked if there was a time they requested a document and did not receive it in a timely manner, one (1) out of two (2) stated they are provided with the documents right away. Additionally, one (1) out of two (2) stated they have not requested documents from the facility.
During interviews with Residents R4-R6’s responsible parties W1-W3, were asked if when they have requested documents from the facility if they received them in a timely manner, three (3) out of three (3) stated they have had no issues and received them right away.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Assistant, Muriel Cabacungan, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250416134005
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES
FACILITY NUMBER: 198320302
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
87468.2(a)(19)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,..following personal rights: (19)To have prompt access to review all of their records and to purchase photocopies of their records.
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Licensee will send copies of R1's documents in thier file to thier representative and will carbon copy (CC) LPA Wendy.Gibbs@dss.ca.gov on the email before the POC due date.
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 Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.
This requirement was not met as evidence based on interviews and record reviews. The licensee did not ensure Resident R1's representitive received copies of documents requested.
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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: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4