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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601591
Report Date: 02/09/2022
Date Signed: 02/09/2022 03:39:50 PM

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: 5DATE:
02/09/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:57 PM
MET WITH:Mona Alcaraz and Lilybelle Calzado TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Management - Deficiencies visit to re-cite deficiencies cited during investigation of Complaint Control Number 11-AS-20211201083611, Case Management visit conducted on 12/07/2021, Case Management visit conducted on 12/09/2021 and to cite deficiencies observed during investigation of a complaint with Complaint Control Number 11-AS-20220204111404.

Complaint Number 11-AS-20211201083611. Based on LPA Coronel's observation and interviews the licensee failed to ensure that the facility is in good repair at all times,
  1. The power in rooms 2,3 and 6 turns off when the circuit breaker trips due to multiple space heaters in use which poses a potential risk to the residents in care.
Case Management Visit 12/07/2021 - the following are deficiencies observed during investigation of a complaint with control number 11-AS-20211201083611.
  1. Portable heaters were accessible to residents R2 and R3 who are diagnosed with dementia.
  2. During record reviews, LPA Coronel did not observe a Needs and Services Plan for resident R1.
  3. 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.
Case Management Visit 12/09/2021 - the following are deficiencies observed during investigation of a complaint with control number 11-AS-20211201083611.
  1. Resident R4 was on Home Health using a g-tube which a Prohibited Health Condition without approval for an exception from Licensing.
  2. On 12/07/2021 around 6pm LPA Coronel observed that resident R1 has not eaten lunch and dinner. R1 stated that they did not like the white bread, meatballs and chicken nuggets served during meals but they were not offered alternatives.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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 6
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: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2022
Section Cited

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Based on LPA observation and interviews the licensee failed to ensure that the facility is in good repair at all times, the power in rooms 2,3 and 6 turns off when the circuit breaker trips due to multiple space heaters in used which poses a potential risk to the resdients in care.
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Type B
02/14/2022
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 R2 and R3, which poses a potential risk to the health and safety of 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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2022
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 R1, which poses a potential health and safety risk to clients in care.
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Type B
02/14/2022
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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2022
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 the licensee failed to submit a written exeption request, for resident R4's restricted health condition.
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Type B
02/14/2022
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. This requirement was not met as evidenced by:
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Based on LPA observation and record review the licensee failed ensure that create a plan to ensure that food service is provided with consideration for food habits of residents. On12/07/2021 R1 was not provided with meal alternatives for lunch and dinner, which poses a potential health and seafty 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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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
VISIT DATE: 02/09/2022
NARRATIVE
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Complaint Number 11-AS-20220204111404. Based on observation, interviews and record reviews conducted by LPA Coronel and LPM Janae Hammond the licensee failed to ensure that the administrator has the knowledge of and ability to conform to the applicable laws, rules and regulations. R1 is being illegally evicted from this facility.

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: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6
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: 02/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2022
Section Cited

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87405(d)(2) Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If... apply. Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement was not met as evidenced by:
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 Based on LPM Hammond's interviews and LPA Coronel's record reviews, the licensee failed to ensure that the administrator have knowledge of and ability to conform with applicable laws, rules and regulations. R1 is being illegally evicted from this facility, which poses a potential health and safety risk to resident 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: 02/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6