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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320303
Report Date: 07/22/2022
Date Signed: 07/22/2022 04:37:07 PM


Document Has Been Signed on 07/22/2022 04:37 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 HOUSEFACILITY NUMBER:
198320303
ADMINISTRATOR:ALCARAZ, MONA MFACILITY TYPE:
740
ADDRESS:3449 ROSEWOOD AVENUETELEPHONE:
(213) 478-0460
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 6DATE:
07/22/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:39 PM
MET WITH:Mona AlcarazTIME COMPLETED:
04:40 PM
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On 7/22/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes 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 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

Structure: The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) bedrooms, (6) bathrooms, living room, family/ dining room, kitchen, garage/ storage and front porch and covered backyard patio area. There is an apartment on the second floor that is rented out to a tenant. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded back 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.

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 hallways cupboards.

Due to time constraints LPA could not complete pre-licensing, LPA will return at a later date.

An exit interview was conducted with Mona Alcaraz, Administrator and a hard copy was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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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