198320302-9-27-2023-11-AS-JHAD-CZMTYG-20240119140840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 09/27/2023
Date Signed: 09/27/2023 02:11:02 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, 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
08/23/2023 and conducted by Evaluator Jeremiah Randle

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230823094517

FACILITY NAME:	BENTLEY SUITES		FACILITY NUMBER:	198320302
ADMINISTRATOR:	AQUINO, ROBIN		FACILITY TYPE:	740
ADDRESS:	851 4TH STREET		TELEPHONE:	(213) 478-0460
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90403
CAPACITY:	44	CENSUS: 35	DATE:	09/27/2023
		UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Muriel Cabacugan Asst Administrator (S1)		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff was not able to provide 911 with resident's medical information
Staff are not able to communicate with resident

INVESTIGATION FINDINGS:

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On 9/27/2023, Licensing Program Analyst (LPA) Jeremiah Randle, conducted a complaint investigation visit to deliver complaint findings to the above-named facility for the allegation(s) listed above. LPA Randle was met by Muriel Cabacugan Asst Administrator (S1). LPA Randle explained to (S1) the purpose of the visit.

The investigation consisted of the following:

On 8/30/23 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced 10-day visit to BENTLEY SUITES. LPA was met by Muriel Cabacugan Asst Administrator (S1)
LPA Randle conducted interviews with (3) staff members, observed resident R1, and interviewed Reporting Party. The LPA also reviewed the following documents provided by Muriel Cabacugan Asst Administrator (S1): Staff roster, Client roster, Residence and Care Agreement, Needs and Services Plan, Hospice information and Physician Report for Resident R1 and Death Report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230823094517

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: 09/27/2023

NARRATIVE

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The Investigation Revealed The Following.

Allegation: Staff was not able to provide 911 with resident's medical information. LPA interviewed three (3) staff members all denied the allegation. LPA reviewed facility documents obtained during the investigation LPA was able to review R1’s file and medical information. S1 informed the LPA that S1 was the staff that call 911 for the resident per R1’s request relayed through staff S2. S1 stated that she spoke to dispatch and informed the operator that R1 was Spanish speaking and would require paramedics that spoke Spanish S1 also stated S1 informed paramedics that the resident R1 was on hospice services. LPA was later informed during interview of Reporting party (RP) Spanish speaking services was requested and provided. S2 stated to LPA that S2 informed S1 that R1 told S2 that R1 wanted to go to the hospital because R1 was not feeling well. In addition, S2 stated to LPA that S2 informed hospice services of R1’s request to go to the hospital while S1 called the paramedics. LPA interviewed staff S3, S3 informed the LPA, that S3 observed R1 appear to be having difficulty breathing R3 then informed S2 which initiated the call to 911. LPA interviewed RP, RP stated to LPA that S1 told RP that R1 was experiencing shortness of breath and labored breathing. LPA was informed by RP that RP was informed R1 was on hospice. RP stated that R1 refused transport to hospital and vitals were normal.

Based on information gathered, the department did not find sufficient evidence to support allegation

Allegation: Staff are not able to communicate with resident. LPA interviewed three (3) staff members all denied the allegation. S1 informed the LPA that S1 was the staff that call 911 for the resident per R1’s request relayed through staff S2 and S3. S1 also stated that support staff of R1 is Spanish speaking including R1’s Social Worker and Hospice Service. LPA interviewed S2,S2 stated to LPA during interview that S2 communicated with R1 daily as she is the med tech and provide R1’s medication and assesses R1’s care. LPA interviewed S3, S3 stated to LPA that S3 is able to communicate with R1, S3 stated that S3 was told by R1 that he was having trouble breathing and that is the reason S3 initiated the emergency response to call 911, S3 stated that he provides care to R1 on a daily basis. LPA was not able to follow up interview R1 as R1 has passed away as of 9/10/2023.

Based on information gathered, the department did not find sufficient evidence to support allegation

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230823094517

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: 09/27/2023

NARRATIVE

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Findings

Based on information gathered, LPA Randle did not find sufficient evidence to support allegation(s)

Staff was not able to provide 911 with resident's medical information.

Staff are not able to communicate with resident.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Robin Aquino Administrator

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jeremiah Randle	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2023

LIC9099 (FAS) - (06/04)

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