198320303-7-25-2022-11-AS-SCIS-CGNQFC-20220725120744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320303
Report Date: 07/25/2022
Date Signed: 07/25/2022 12:08:03 PM

Document Has Been Signed on 07/25/2022 12:08 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 HOUSE		FACILITY NUMBER:	198320303
ADMINISTRATOR:	ALCARAZ, MONA M		FACILITY TYPE:	740
ADDRESS:	3449 ROSEWOOD AVENUE		TELEPHONE:	(213) 478-0460
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Mona Alcaraz-Administrator		TIME COMPLETED:	12:15 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 continuation inspection to the above facility for the 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 6 clients, 5 non-ambulatory, 1 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Bedrooms Residents: LPA’s observed 6 resident bedrooms, 5 bedrooms are for non-ambulatory and 1 bedroom is for bedridden. Bedrooms 1, 2, 3, 4, 5 and 6, have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. Drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Bathroom: Facility has 6 client bathrooms. 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. 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. Two fully charged fire extinguishers were found, one in kitchen and one in dining room. Toxins: Toxins locked/stored in hall cupboard and under kitchen sink. Water temperature: Water temperature in kitchen and bathrooms measured between 123F to 143F. 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)

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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 HOUSE	FACILITY NUMBER: 198320303
	VISIT DATE: 07/25/2022

NARRATIVE

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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: Eight (8) smoke detectors are hardwired and interconnected. 3 carbon monoxide detectors were found in dining room, kitchen and hallway to client rooms. They were tested and are fully operational.

Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. 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.

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

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

Doors have auditory devices to monitor exits.

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

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)

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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 HOUSE	FACILITY NUMBER: 198320303
	VISIT DATE: 07/25/2022

NARRATIVE

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Fire clearance: Fire Clearance was approved on 6/17/2022 for 1 bedridden client and 5 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:
-Outside activity area is not properly enclosed with self-closing latches
-Outside activity area has four chair and there should by 6.

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

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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