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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320302
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:36:19 PM


Document Has Been Signed on 12/14/2023 03:36 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: 36DATE:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Muriel Cabacugan TIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) David España is conducting a case management-other visit due to LPA observations on 12/13/2023 deficiencies not related to a complaint that is being investigation today. (Control # 11-AS-20231205153025) LPA met with S#1 who assisted with visit. Upon arriving at the facility, LPA met with S#1 and S#2 who assisted with the visit. The purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.
On 12/13/2023 Licensing Program Analyst (LPA) David España confirmed there were Thirty-Six (36) total residents in care. LPA confirmed there are Ten (10) total staff employed as of 12/13/2023. LPA confirmed there is only One (1) resident in care who receives oxygen as of 12/14/2023. LPA confirmed there are Six (6) total staff working at the time of visit 12/14/2023. LPA confirmed there are Twenty-Two (22) total residents in care with dementia at the time of visit 12/14/2023. LPA confirmed there are Twelve (12) total residents in care with wheelchairs at the time of visit 12/14/2023. LPA confirmed there are Seventeen (17) total residents in care with diapers at the time of visit 12/14/2023.
The LPA also reviewed the following documents provided by Muriel Cabacugan Assistant Administrator (S1): Staff roster and Client roster. Observation on 12/13/23 at 10:25am made while conduction a walkthrough of the physical plant, LPA observed Room #16 and Room #15 front doors and Room walls with large holes in the drywall that needs maintenance. LPA and S#1 observed Room #3 window bathroom screen missing. LPA and S#1 observed bathroom window not working (did not stay on its track). LPA and S#1 also observed Room #14 and Room #13 had a strong urine odor in both rooms. LPA and S#1 observed private room #12 missing window screen next to the bathroom. LPA and S#1 observed outdoor walkways with materials with little accessibility towards exit of facility (back of facility). LPA and S#1 also observed materials with little accessibility entering the laundry area towards side of facility. Continued on LIC 809-C


SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 12/14/2023 03:36 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: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2024
Section Cited
CCR
87303(f)(1-2)

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87303(f)(1-2) Maintenance and Operation
(f)Solid waste shall be stored and disposed of as follows: (1)Solid waste shall be stored, located and disposed of ...transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. (2)Syringes and.. with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.
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Licensee will fix windows, screens in despair, accessibility, and drywall of the facility by POC due date. Licensee will email proof of correction to David.espana@dss.ca.gov.
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Based on observation, and interview, the licensee did not comply with the section cited above in, screens in despair, accessibility, and drywall, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/14/2024
Section Cited
CCR87303(a-e)

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87303 (a-e) Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision... the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition…(c) All window screens shall be clean and maintained in good repair. (d)There shall be...the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. (e)Water supplies and.... maintained as follows: (1)All community care facilities where water for human consumption is from a private…
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Licensee will address flammable grasses, no access door to side of facility, pigeons and pigeon cages, and flies and insects at the facility by POC due date. Licensee will email proof of correction to David.espana@dss.ca.gov.
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Based on observation, and interview, the licensee did not comply with the section cited above in, flammable grasses, no access door to side of facility, pigeons and pigeon cages, and flies and insects, which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 12/14/2023
NARRATIVE
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LPA and S#1 observed during tour observed front and side of facility, and the left-hand side of the facility, noted overgrown grass with no access to the length of the facility. LPA and S#1 noted debris and yellow overgrown grass. LPA interviewed S#1 about access to the side of facility, and S#1 stated there was no door access to the area. LPA noted that flammable grasses blanketed the side of the facility. Lastly, LPA and S#1 observed in the front yard with overgrown plants. LPA and S#1 toured the back side of the facility and noted that the trash bins were not closed. LPA and S#1 observed flies and insects within the facility. LPA and S#1 additionally noted pigeons and pigeon cages within the facility.

The following deficiency is being cited in accordance with California Code of Regulations, Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303 (a-e) Maintenance and Operation and Title 22, Division 6 Chapter 8 Article 05. Physical Environments and Accommodations 87303(f) (1-2) Maintenance and Operation on the LIC 809D.


Exit interview was conducted with facility representative and appeal rights as well as report was provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023
LIC809 (FAS) - (06/04)
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