198601877-4-13-2022-11-AS-MVAO-CDQTMY-20220422145154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601877
Report Date: 04/12/2022
Date Signed: 04/13/2022 07:50:53 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2022 and conducted by Evaluator Martessa Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220407160633

FACILITY NAME:	BENTLEY MANOR BY SERENITY CARE HEALTH		FACILITY NUMBER:	198601877
ADMINISTRATOR:	MONA ALCAREZ		FACILITY TYPE:	740
ADDRESS:	3425 MCLAUGHLIN AVE.		TELEPHONE:	(213) 478-0800
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	27	CENSUS: 23	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Mona Alcarez		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Regarding allegation: Resident at the facility had scabies

INVESTIGATION FINDINGS:

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On 4/12/22, Licensing Program Analyst (LPA) Martessa Brown conducted a 10 day visit to the above facility to investigate the above allegation. LPA was allowed entry inside and met with Mona Alcarez, the facilities Administrator and the purpose of today’s visit was explained.

The investigation consisted of the following: on 4/12/22, LPA Brown toured the physical plant, residents’ bedrooms and residents #1-2 medications. LPA conducted interviews with the Mona Alcarez, the administrator and staff members #1-4 and residents #1-5. LPA requested and obtained the following documents: Resident/Staff Roster, Incident report for resident (R1) and physicians reports R1 & R6 and emergency contacts.

The investigation revealed the following:

Regarding allegation: Resident at the facility had scabies

LIC 9099-C is on the next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220407160633

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 MANOR BY SERENITY CARE HEALTH	FACILITY NUMBER: 198601877
	VISIT DATE: 04/12/2022

NARRATIVE

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On 4/12/22 LPA conducted an interview with the administrator, she stated resident (R1) was residing at the facility and was transported to the hospital on 3/31/22 due to not eating. Administrator stated that son had notified her the resident( R1) tested positive for scabies. Resident was still residing at the hospital. The Administrator stated they took the necessary precautions when they found out (R1) was diagnosed with scabies. She stated painted (R1’s) bedroom and wash all residents’ clothes in hot water. LPA conducted interviews with staff #1-4, staff stated they were unaware of any resident being diagnose with scabies. Staff stated the residents at the facility have dry skin and frequently itch. Staff stated they did not notice any residents with rashes. On 4/12/22, LPA conducted interviews with resident #1-5. All residents except for 1 stated they had a rash on their body. Residents #1 - 5 stated they have experiencing itching. On 4/12/22, LPA observed resident #R6 had grey patches on their hands and skin was dried. LPA reviewed R6 Mobile physicians report dated 3/30/22 that resident had expiring itching and to apply cream, in addition reason for visit was for access itching.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit Interview Conducted, appeal rights were explained and a copy of this report was provided to administrator.

See LIC-9099-D on the next page.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220407160633

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 MANOR BY SERENITY CARE HEALTH	FACILITY NUMBER: 198601877
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/14/2022 Section Cited CCR 82711(a)(1)	1 2 3 4 5 6 7	87211: Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible within seven days of the occurrence...	1 2 3 4 5 6 7	Licensee will develop a plan on how they will clean facility due to scabies, in addition to notify residents doctors, family members, health department and Community Care Licensing (CCL). Licensee will also review (Reporting Requirements) and submit a statement that they have reviewed cited regulation.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on LPAs observation, interviews conducted and documents reviewed, Licensee did not ensure all residents were properly screen , also did not notified the health department and CCL. This is a potential health and safety risk to all residents in care.	8 9 10 11 12 13 14	Facility will submit proof to CCL attention to LPA Brown by POC due date 4/14/22.
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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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Martessa Brown	TELEPHONE: (714) 743-4597
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

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