198320302-7-27-2023-11-AS-RORN-CUCUG4-20230803153342

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320302
Report Date: 07/27/2023
Date Signed: 07/27/2023 01:18:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
11/14/2022 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221114142817

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:	07/27/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Muriel Cabacungan, Asst. Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility staff yelled at resident.
Facility staff inappropriately touched resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Asst. Administrator (A2: Muriel Cabacungan). LPA/RA conducted a risk assessment prior to entering facility. A2 informed LPA/RA that the facility has no COVID cases nor do the residents or staff have symptoms. The purpose for today’s visit is to conduct a subsequent visit to deliver findings pertaining to the above-mentioned allegations.

An initial 10-Day visit was conducted by LPA Martessa Brown on 11/16/22 with Staff #1 (S1: Divine Diaz). During this visit, LPA interviewed Staff #1 and Residents #2 - #4. LPA reviewed and obtained copies of the following documents: resident/staff roster, resident R1's records and incident report. LPA attempted to contact R1; however, the resident’s contact number was disconnected at the time. During today’s subsequent visit, LPA/RA Elizabeth Ceniceros made a second attempt to reach R1 to no avail. RA interviewed Asst. Administrator (A2), Staff #3 (S3), Staff #4 (S4), and Witness #2 (W2). RA contacted

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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-20221114142817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2023

NARRATIVE

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R1’s nearest relative who confirmed R1’s number is disconnected and any correspondence to be mailed to family member.

Regarding Allegation #1: this investigation revealed based on interviews conducted with staff and residents that facility staff do not yell at its residents. Staff also informed LPA Martessa Brown that they are not aware of a report that a staff person yelled at Resident #1. LPA Brown interviewed one (1) staff member and RA Elizabeth Ceniceros interviewed three (3) staff members; of which, four of four staff members corroborated that they had not witnessed a facility staff member yelling at residents nor Resident #1. LPA Brown interviewed four (4) residents; of which, four of the four corroborated that they had not witnessed a facility staff member yelling at residents nor at Resident #1. RA Ceniceros interviewed Resident #1’s family member who confirmed that Resident #1 is doing fine at their new facility – following their move out in June 2023. A review of facility staff training records documented facility staff last training topics on “Personal Rights” were conducted on 02/25/22 and “Mandated Reporting” conducted on 10/12/22.

Based on the evidence gathered and interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff yelled at resident is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews conducted with staff and residents that Resident #1 has not been inappropriately touched by facility staff. LPA Martessa Brown interviewed one (1) staff member and RA Elizabeth Ceniceros interviewed three (3) staff members; of which, four out of the four corroborated that they had not witnessed staff inappropriately touch a resident nor Resident #1. RA Ceniceros interviewed Resident #1’s family member who confirmed that Resident #1 is doing fine at their new facility – following their move out in June 2023. LPA Brown interviewed four (4) residents; of which, four out of the four corroborated that they had not witnessed a facility staff member inappropriately touch residents nor Resident #1. A review of facility staff training records documented facility staff last training topics on “Personal Rights” were conducted on 02/25/22 and “Mandated Reporting” conducted on 10/12/22.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20221114142817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/27/2023

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 26 27 28 29 30 31 32	or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility staff inappropriately touched resident is found to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report provided to Asst. Administrator, Muriel Cabacungan.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 224-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3