198320302-7-25-2022-11-AS-SCIS-CGP2Q9-20220725173534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320302
Report Date: 07/25/2022
Date Signed: 07/25/2022 05:35:44 PM

Document Has Been Signed on 07/25/2022 05:35 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

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: 27	DATE:	07/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Mona Alcaraz		TIME COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/25/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes and Perry Scott conducted an announced inspection to the above facility for purpose of a change of ownership pre-licensing evaluation. An application was submitted to Community Care Licensing Department(CCLD) on 04/23/2022, for a Change of Ownership for a Residential Care for the Elderly. The requested capacity is for 44 clients,40 non-ambulatory, 4 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Structure: The facility is a two-story structure located in a residential neighborhood. It consists of the following: twenty two (22) resident rooms with attached baths, lounge, outdoor patio, dining area, kitchen, pantry and laundry room. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded inner yard with a covered patio, tables and chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Bedrooms Residents: LPA observed 22 resident bedrooms, 4 bedrooms are for bedridden and 18 bedrooms are for non-ambulatory. Bedrooms 19, 18, 17, 16, 14, 13, 8, 7, 6, 4, 3 and 2 have two beds, two chairs, nightstands, closet, two dressers with several drawers and most had overhead lighting. Bedrooms 22, 12, 11, 9, 5, 1 have one bed, one chair, one-night stand, closet or wardrobe, a dresser with several drawers and most had overhead lighting. Drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES	FACILITY NUMBER: 198320302
	VISIT DATE: 07/25/2022

NARRATIVE

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Bathroom: Facility has 22 client bathrooms and one staff bathroom. Bathrooms have working toilets, wash basins and showers. There are grab rails next to both the toilets and the showers as well as nonskid mats in showers. LPA observed adequate lighting in hallway leading to bathrooms.

Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene supplies stored in a first-floor cupboard, second floor cupboard and laundry room and.

Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline which was called by LPA and is operational. Emergency Disaster Plan posted & readily available for review on the wall. Six fully charged fire extinguisher were found, one in kitchen and one in downstairs hallway and one in upstairs hallway.

Toxins: Toxins locked/stored in laundry room.

Water temperature: Water temperature in kitchen and bathrooms measured between 99.8F to 144F.

Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in kitchen drawers. Food supply was adequate and stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items.

Smoke Detectors: Twenty-four (22) smoke detectors where found. Two(2) were missing from rooms 2 and 3, while the smoke detectors in rooms 1, 13, 14 and 15 were not operational. 5 carbon monoxide detectors was found, they were tested and are fully operational.

Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen and another in the pantry. Refrigerator and freezer are at the correct temperature for food storage.

Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients.

Continued on 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: BENTLEY SUITES	FACILITY NUMBER: 198320302
	VISIT DATE: 07/25/2022

NARRATIVE

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Clients & Staff Files: Applicant will not be handling cash resources of clients. Records of staff and clients are stored in cabinets at staff desk.

Reading Material, Games, Equipment & Materials: The facility has an activity calendar and provides puzzles other games and papercrafts as well as ball toss and bingo.

Doors have auditory devices to monitor exits.

Pool/Jacuzzi & Pets: LPA's did not observe any pets or bodies of water at the facility.

Fire clearance: Fire Clearance was approved on 6/7/2022 for 4 bedridden client and 40 non-ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits.

Component III: Conducted at the Pre-Licensing visit, on 7/22/2022 at Bentley Manor, information provided about how to operate the facility within substantial compliance.

The following corrections need to be completed before licensure:
1. Bathrooms as well as kitchen sink had water temperatures ranging from 99.8F to 144F.
2. Bedrooms 3, 28, 15 were shared rooms and were missing the second bed and room 10 had no bed at all.
3. Bedrooms 12, 17, 18, 19, and 21 had no light.
4. Facility layout does not match floor plan provided to CAB.
5. Bedrooms 2 and 3 are missing smoke detectors.
6. Smoke detectors in room 1, 13, 14, and 15 are not operational.

Proof of correction requested for 7/26/2022

An exit interview was conducted, and a printed copy of this report was given to the applicant to the applicant. Accordingly, LPA Stephanie Cifuentes will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022

LIC809 (FAS) - (06/04)

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