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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320303
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:00:32 PM


Document Has Been Signed on 08/11/2022 02:00 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:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lilybelle CalzadoTIME COMPLETED:
02:05 PM
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8/11/2022 at 1:00pm Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management visit to the Bentley House. LPA explained the purpose of the visit was to speak with one of the residents and was allowed entry.

LPA Cifuentes spoke with resident 1(R1) and provided them with information.

No deficiencies were assessed during this visit.

An exit interview was conducted with Staff Lilybelle Calzado and a hard copy of this report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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