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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320303
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:43:41 AM

Substantiated


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
12/12/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20221212120312
FACILITY NAME:BENTLEY HOUSEFACILITY NUMBER:
198320303
ADMINISTRATOR:ALCARAZ, MONA MFACILITY TYPE:
740
ADDRESS:3449 ROSEWOOD AVENUETELEPHONE:
(310) 398-6264
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 6DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:STAFF LILYBELLE CALZADOTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Licensee had liability insurance that did not include required coverage for resident’s injuries.
The Licensee has no current liability insurance.
INVESTIGATION FINDINGS:
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This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Jose Calderon for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA Jose Calderon met with Staff Lilybelle Calzado and explained the reason for today’s inspection. There was concern that the Licensee representative had liability insurance that did not include the required coverage for resident’s injuries.

On 12/13/2022, LPA Jose Calderon conducted the initial 10-day complaint investigation and conducted interviews from 9:30 a.m. to 2:30 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Facility staff stated that this facility had liability insurance with an effective date of 08/26/2022. Further investigation was required.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 6
Control Number 11-AS-20221212120312
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 HOUSE
FACILITY NUMBER: 198320303
VISIT DATE: 05/17/2023
NARRATIVE
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On 12/14/2022 the LPA Jose Calderon reviewed the insurance records for clarification. Licensee presented multiple Certificate of Liability Insurance.

The Certificate of Liability Insurance dated 09/02/2022 for Policy Number ending in 191-0 shows an effective date of 08/26/2022 thru ending date of 8/26/2023. This corroborates with the facility staff’s statement. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy is shared by this facility and six (6) other facilities, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility.

On 12/6/2022, the Policy Number ending in 191-0 dated 9/2/2022 was rewritten into Policy Number ending in Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] and there was no gap between these policies since 08/26/2022 thru ending date of policy of 8/26/23. This is a separate, stand-alone business liability insurance for this facility.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 11-AS-20221212120312
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 HOUSE
FACILITY NUMBER: 198320303
VISIT DATE: 05/17/2023
NARRATIVE
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An Insurance Binder dated 12/08/2022 for Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] identified multiple policy exclusions, including exclusions for “Infestation”, “Bedsores”, “Elopement (General Liability)”, and “Treatment of Coronavirus”. Per witness interview, the exclusion for “Bedsores” means that this policy does not cover resident injuries due to bedsores if there is evidence of negligence on the part of the Licensee. Witnesses also stated that the exclusions for “Infestation” and “Elopement (General Liability)” mean that the Licensee is not responsible for obtaining insurance for injuries to residents from infestations and elopements. Due to the exclusions, this policy does not include the required coverage for resident injuries caused by the negligent acts or omissions to act of, or neglect by, the Licensee or its employees.

The Certificate of Liability Insurance dated 12/13/2022 for policy number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] shows an effective date of 12/06/2022.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20221212120312
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 HOUSE
FACILITY NUMBER: 198320303
VISIT DATE: 05/17/2023
NARRATIVE
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While the Licensee had insurance policies in place from 08/26/2022, the policies [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] did not provide the required coverage due to the exclusions they contained; and, because this facility was sharing a single policy with six (6) other facilities (Bentley Suites 198320302; Henrietta's Leven Oaks 198603586; Kaego's Richman Gardens 306006189; Bentley House 198320303; Bentley Manor 198320301; Bentley Hills 195850277; Henrietta's Home 198603585).

Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, this facility did not have its own liability insurance coverage that is compliant with Title 22 Regulations, and licensee has no current liability insurance. As a result, the above-mentioned allegations are being substantiated. Please see LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations.



An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20221212120312
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 HOUSE
FACILITY NUMBER: 198320303
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/24/2023
Section Cited
HSC
1569.605
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HSC 1569.605 –Liability insurance… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA Calderonn by POC due date (05/24/23).
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This requirement was not met as evidenced by: Based on liability insurance records reviewed, interviews conducted with Administrator and relevant witnesses, it was determined that the licensee did not have required liability insurance coverage for 08/26/2022 to present which poses an immediate safety risk to residents in care. Based on interviews and records review, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts specified which posed a potential Health, Safety, or Personal Rights risk to 4 persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/12/2022 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20221212120312

FACILITY NAME:BENTLEY HOUSEFACILITY NUMBER:
198320303
ADMINISTRATOR:ALCARAZ, MONA MFACILITY TYPE:
740
ADDRESS:3449 ROSEWOOD AVENUETELEPHONE:
(310) 398-6264
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 6DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:STAFF LILYBELLE CALZADOTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
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5
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Licensee misrepresented to the Department that they have liability insurance

INVESTIGATION FINDINGS:
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This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Jose Calderon for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPA Jose Calderon met with Staff Lilybelle Calzado and explained the reason for today’s inspection. There was concern that the Licensee representative misrepresented to the Department that they had liability insurance.
On 12/13/2022, LPA Jose Calderon conducted the initial 10-day complaint investigation and conducted interviews from 9:30 a.m. to 2:30 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Interviews conducted with facility staff and witnesses revealed that facility was actively working with multiple insurance agencies to finalize the policy to comply with Title 22 Regulations. Based on review of the policies submitted to the Department between 08/26/2022 and 12/06/2022 there is insufficient information to support the allegation.
An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6