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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601591
Report Date: 08/18/2021
Date Signed: 08/18/2021 11:42:26 AM

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
MONTEREY PARK, CA 91754
FACILITY NAME:BENTLEY HOUSEFACILITY NUMBER:
198601591
ADMINISTRATOR:BIOSEH OGBECHIEFACILITY TYPE:
740
ADDRESS:3449 ROSEWOOD AVETELEPHONE:
(213) 478-0800
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 4DATE:
08/18/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lilyvelle Calzado, Lead Staff TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced Case Management POC visit to this facility to Bentley Manor By Serenity Care Health. LPA arrived and met with Lead Staff, Lilyvelle Calzado. LPA explained the reason for the visit.

On 07/30/2021, LPA Jones conducted a case management visit and cited the facility for failing to provide proof of liability insurance coverage under HEALTH & SAFETY CODE 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.

On 08/18/2021, LPA Jones conducted a follow up Case Management POC follow up visit with the facility to ensure that the requirement has been met and the facility is in compliance.

During the visit, Lead Staff, Lilyvelle Calzado advised LPA that the corporate office is still handling the liability issue coverage and was unable to provide LPA with any documentation.

The facility failed to comply with the POC that was issued on 07/30/21 and new a citation is being issued under regulation. 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.



A copy of the report was issued to Lead Staff, Lilyvelle Calzado.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY HOUSE
FACILITY NUMBER: 198601591
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2021
Section Cited

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Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and dollars ($1,000,000) per occurrence and three
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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.
This requirement has not been met :Based on observation and interviews conducted the failed to provide proof of liability insurance during the visit.
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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: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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