198320302-9-18-2026-11-AS-UCOL-DYGPM7-20261002112551

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 09/18/2026
Date Signed: 09/18/2026 01:39:06 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, 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
11/20/2025 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20251120155321

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: 36	DATE:	09/18/2026
		UNANNOUNCED	TIME BEGAN:	08:46 AM
MET WITH:	ADMINISTRATOR ROBIN AQUINO		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not address resident's change of condition resulting in resident's hospitalization.
Staff did not seek medical attention in a timely manner.
Staff inappropriately restrained resident.
Staff isolated resident.
Staff did not provide resident with activities while in care
Facility is in disrepair.

INVESTIGATION FINDINGS:

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On 09/18/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Bentley Suites and was greeted by staff Muriel Cabacungan (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: On 01/08/2026 LPA Calderon interviewed Staff S1-S4, residents R1-R4, Witness W1. On 09/18/2026 LPA Calderon interviewed residents R3-R10. LPA Calderon obtained the following records: Admission Agreement (dated 06/29/2024), Incident report (dated 06/30/2025), Email regarding elevator service (dated 07/14/2025), Lift Tech Company (dated 07/17/2025 to 07/22/2025), Physician report (dated 07/23/2025), Activities Calander (dated 08/2025 to 01/2026), Letter from Lift Tech (dated 09/16/2025), Incident report (dated 10/03/2025) for R1. Toured the facility with S1 on 11/21/2025 and 01/08/2026.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026

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-20251120155321

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: 09/18/2026

NARRATIVE

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Regarding Allegation: Staff did not address resident's change of condition resulting in resident's hospitalization. It is being alleged that staff did not address the residents’ changing conditions, leading to an undiagnosed UTI and a month-long ICU stay. Records review indicates the following: The incident report shows that on 10/03/2025 at 7:30 a.m., R1 was found by S2 not feeling well. S2 reported to S1 that R1 had low blood pressure, 911 was immediately called, and R1 was transported to UCLA Santa Monica for further evaluation. Interviews revealed the following: 7 out of 10 residents denied the allegation 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff denied the allegation. R1 could not be interviewed due to health issues. Based on interviews and supporting documentation, the “the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “staff did not address resident change of condition resulting in residents’ hospitalization.” is found to be UNSUBSTANTIATED.

Regarding Allegation: Staff did not seek medical attention in a timely manner.

This complaint alleged that the facility staff did not seek timely medical care for R1’s Low Blood Pressure. Records review indicate the following: GK Hospice care (dated 05/27/2025) indicates that R1 had low blood pressure. Physician report (dated 07/23/2025) indicates that R1 had low blood pressure. The incident report shows that on 10/03/2025 at 7:30 a.m., R1 was found by S2 not feeling well. S2 reported to S1 that R1 had low blood pressure, 911 was immediately called, and R1 was transported to UCLA Santa Monica for further evaluation. Interviews revealed the following: 7 out of 10 residents denied the allegation 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff denied the allegation. R1 could not be interviewed due to health issues. Based on interviews and supporting documentation, the “the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “staff did not address resident change of condition resulting in residents’ hospitalization.” is found to be UNSUBSTANTIATED.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20251120155321

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: 09/18/2026

NARRATIVE

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Regarding Allegation: Staff inappropriately restrained resident.This complaint alleges that staff places bed rails on both sides of residents’ beds to prevent them from getting out of bed. Records review indicate the following: Admission agreement (dated 06/29/2024) indicates that R1 had health issues. GK Hospice Care Inc.’s Durable Medical Equipment list (dated 09/27/2025) indicates that R1 was provided with a hospital bed with full rails on 04/30/2025. Interviews revealed the following: 7 out of 10 residents denied the allegation 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff denied the allegation. R1 could not be interviewed due to health issues. Based on interviews and supporting documentation, the “the allegation may have happened or is valid, but there is not a preponderance Sof the evidence to prove that the alleged violation occurred.” therefore, the allegation of “staff inappropriately restrained resident.” found to be UNSUBSTANTIATED.

Regarding Allegation: Staff isolated residents.

It is being alleged that staff are isolating residents who live on the second floor. Records review indicate the following: On 01/08/2026 LPA Calderon reviewed incident report (dated 06/30/2025), elevator not working notified Lift Tech Company. Reviewed letter from Lift Tech to facility states that part ordered will arrive between 07/17/2025 to 07/22/2025 and the elevator will not be working. Reviewed letter from Lift Tech to facility dated 09/16/2025 states that the elevator will not be working due to main fuse needs to be replaced. GK Hospice care (dated 05/27/2025) indicates that R1 had medical issues. Interviews revealed the following: 7 out of 10 residents denied the allegation 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff denied the allegation. R1 could not be interviewed due to health issues. Staff indicate that the facility elevator was not working on and off between July 2025 and September 2025. LPA Calderon toured the facility with S1 on 11/21/2025 and again on 01/08/2026, and LPA noted that the facility elevator was working." Based on interviews and supporting documentation, the “the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “staff isolated resident.” is found to be UNSUBSTANTIATED.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20251120155321

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: 09/18/2026

NARRATIVE

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Regarding Allegation: Staff did not provide residents with activities while in care.

This complaint alleged that the facility staff did not provide R1 with activities while in care. Records review indicate the following: Reviewed activities Calander (dated 08/2025 to 01/2026) indicates that the facility offered activities for residents in care. LPA Calderon toured the facility and noted the activities Calander posted on the wall near the dining room. LPA Calderon noted the TV room with books, and other things to do. Interviews indicate the following: On 05/29/2026 W1 indicates that R1 due to the elevator not working, due to restraining R1 in bed R1 was unable to interact with other residents and R1 could not watch TV. R1 could not be interviewed due to health issues. On 01/08/2026 LPA Calderon interviewed 7 out of 10 residents deny the allegation. 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff deny the allegation. Based on interviews and supporting documentation, the “the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.” therefore, the allegation of “staff did not provide residents with activities while in care.” is found to be UNSUBSTANTIATED.

Regarding Allegation: Facility is in disrepair.

This complaint alleged that facility elevator is in disrepair. Records review indicate the following: On 01/08/2026 LPA Calderon reviewed incident report (dated 06/30/2025), elevator not working notified Lift Tech Company. Reviewed letter from Lift Tech to facility states that part ordered will arrive between 07/17/2025 to 07/22/2025 and the elevator will not be working. Reviewed letter from Lift Tech to facility dated 09/16/2025 states that the elevator will not be working due to main fuse needs to be replaced. Interviews revealed the following: 7 out of10 residents denied the allegation, 3 out of 10 residents could not be interviewed due to health issues and 4 out of 4 staff denied the allegation. R1 could not be interviewed due to health issues. Staff indicate that the facility elevator was not working on and off between July 2025 and September 2025. LPA Calderon toured the facility with S1 on 11/21/2025 and again on 01/08/2026, and LPA noted that the facility elevator was working." Based on interviews and supporting documentation, the preponderance of evidence standard has not been met therefore, the allegation of “Facility is in disrepair.” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report were provided to the Staff (S1).No deficiencies cited during today's visit.

An exit interview was conducted, and a copy of the Complaint Report was provided to the Staff Muriel Cabacungan (S1).

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2026

LIC9099 (FAS) - (06/04)

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