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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 06/28/2024
Date Signed: 06/28/2024 12:47:45 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
06/21/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240621122422
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: 37DATE:
06/28/2024
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Muriel Hernandez Cabacungan, Assistant AdministratorTIME COMPLETED:
01:02 PM
ALLEGATION(S):
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Facility lifting device is inoperable.
INVESTIGATION FINDINGS:
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On 06/28/2024 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by Muriel Hernandez Cabacungan, assistant administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the facility.
The investigation consisted of the following:
On 06/28/2024 LPA requested and reviewed facility documents and toured the facility. LPA interviewed three (3) out of thirty-seven (37) residents (R1-R3), one witness (W1) and four (4) out of eleven (11) staff (S1-S4).
The investigation revealed the following:
Regarding the allegation: "Facility lifting device is inoperable."; it has been alleged that the lift at the above-mentioned facility is currently inoperable, which makes a resident feeling trapped upstairs. Between 09:30AM and 10:00AM, on 06/28/2024, LPA observed 3 "out of service" tags located on the various controls of the lift, to prevent any residents from attempting to use the lift.
Report continues, see LIC9099C.
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
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-20240621122422
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: 06/28/2024
NARRATIVE
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Interviews revealed that 4 out of 11 staff, one witness and one (1) out of 3 residents have agreed with the allegation.

Record reviews revealed that communications between an elevator service company and the above-mentioned facilities' Administrator (S5) have been in contact between the dates of 06/15/2024 and 06/28/2024 to repair the lift.

Based on record reviews, LPA's observation 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 LIC 9099D.

An exit interview was conducted with Muriel Hernandez Cabacungan, Assistant Administrator (S1), and a copy of facilities’ appeal rights and this report has been provided.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240621122422
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: 06/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations,
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Assistant Administrator and LPA have agreed that the facility will send video evidence of a working lift, on or prior to the POC due date, via email, to LPA at Mario.Leon@DSS.CA.GOV
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furnishings and equipment.
This has not been met as evidenced by:
Licensee has yet to repair the lift which would allow non-ambulatory resident(s) to freely travel from the second story of the facility to the ground floor.
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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) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3