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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601591
Report Date: 12/07/2021
Date Signed: 12/10/2021 09:41:17 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:
12/07/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:Mona Alcaraz and Lilyvelle CalzadoTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel and LPA Ngozi Nwaokoro conducted an unannounced Case Management - Deficiencies visit to document deficiencies observed during investigation of a complaint with control number 11-AS-20211201083611. LPAs spoke to the administrator Mona Alcaraz met with Lead Staff, Lilybelle Calzado and the purpose of today's visit was explained.

During todays visit LPA observed that portable heaters were accessible to residents R1 and R3 who are diagnosed with dementia.

During todays record reviews conducted, LPA Coronel did not observe a Needs and Services Plan for R2.

The deficiencies noted above and deficiencies cited during investigation of complaint with control number 11-AS-20211201083611 indicate that the licensee failed to ensure that Administrator qualification requirements were met.

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: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
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 3
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: 12/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited

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87705(d) Care of Persons with Dementia. In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement was not met as evidenced by:
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Based on Record reviews and LPA observation, the licensee failed to ensure that heaters were inaccessible to residents with dementia, LPA observed that heaters were accessible to residents R1 and R3, which poses a potential risk to the health and safety of residents in care.
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Type B
12/28/2021
Section Cited

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87457(a)(1)Pre-Admission Appraisal - General. Prior... resident ... shall be interviewed by the licensee...admissions. Sufficient information about the facility and its services shall be provided... admission.(2) The... resident's desires regarding admission, and his/her background, including...specific service needs,...discussed.
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This requirement was not met as evidenced by: Based on record reviews and interviews conducted: the licensee failed to ensure that residents are interviewed prior to admission, LPA did not observe an needs and services plan for R2, which poses a potential health and safety risk to clients 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: 12/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2021
Section Cited

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87405(d)(1) Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If ...apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement was not met as evidenced by:
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Based on record reviews the licensee failed to ensure that the administrator has knowledge of the requirements for providing care and supervision appropriate to the residents, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 12/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3