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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 03/24/2022
Date Signed: 03/24/2022 09:50:36 PM


Document Has Been Signed on 03/24/2022 09:50 PM - It Cannot Be Edited

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 MANOR BY SERENITY CARE HEALTHFACILITY NUMBER:
198601877
ADMINISTRATOR:MONA ALCAREZFACILITY TYPE:
740
ADDRESS:3425 MCLAUGHLIN AVE.TELEPHONE:
(213) 478-0800
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:27CENSUS: 22DATE:
03/24/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Eden Del EspiritusantoTIME COMPLETED:
02:15 PM
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On 3/24/22 at 1:15 p.m., Licensing Program Analyst/ (LPA) Susan Campos conducted an unannounced Case Management visit to the Bentley Manor. LPA was allowed entry into the facility by Eden Del Espiritusanto, Caregiver. LPA explained to Ms. Del Espiritusanto the purpose of today's visit is to follow up on Proof of Liability Insurance citation issued on September 24, 2021.

The facility has failed to comply with the POC that was issued on 09/24/2021. Additional citations are being issued under regulation 1569.605 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 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.

Civil Penalties assessed and an exit interview was conducted with Eden Del Espiritusanto. A copy of the LIC 809 report and appeal rights were provided to Ms. Del Espiritusanto.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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