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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601591
Report Date: 12/09/2021
Date Signed: 12/10/2021 09:39:36 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:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:34 AM
MET WITH:Mona Alcaraz and Lilybelle Calzado TIME COMPLETED:
02:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Management - Deficiencies visit to document deficiencies observed during investigation of a complaint with control number 11-AS-20211201083611. LPA spoke to the administrator Mona Alcaraz met with Lead Staff, Lilybelle Calzado and the purpose of today's visit was explained.

On 12/07/2021 LPA observed that resident R4 was on Home Health using a g-tube a Prohibited Health Condition without approval for an exception from Licensing.

On 12/07/2021 around 6pm LPA observed that resident R2 has not eaten lunch and dinner. R2 stated that they did not like the white bread, meatballs and chicken nuggets served during meals but they were not offered alternatives.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.. An exit interview was conducted and plans of correction were developed. A hard copy of this report and appeals rights were provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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
MONTEREY PARK, CA 91754

FACILITY NAME: BENTLEY HOUSE
FACILITY NUMBER: 198601591
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited

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87616(a) Exceptions for Health Conditions. As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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This requirement was not met as evidenced by:
Based on LPA observation and record review te licensee failed to submit a written exeption request, for resident R4's restricted health condition.
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Type B
12/28/2021
Section Cited

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87555(b)(5) General Food Service Requirements. The following food service requirements shall apply: Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents.
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This requirement was not met as evidenced by:
Based on LPA observation and record review the licensee failed to submit a written exeption request, for resident R4's restricted health condition.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021
LIC809 (FAS) - (06/04)
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