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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 05/12/2022
Date Signed: 05/12/2022 08:55:54 PM


Document Has Been Signed on 05/12/2022 08:55 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: 27DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Mona AlcarezTIME COMPLETED:
12:43 PM
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On 5/12/22, at 10:42am, Licensing Program Analyst (LPA) Susan Campos conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was allowed entry into the facility by Mona Alcarez, Administrator. LPA met with Ms. Alcarez and explained the purpose of the visit. The facility is licensed to operate RCFE and dementia residents, that includes twenty-seven (27) non-ambulatory residents, of which 5 may be bedridden, and may retain up to 8 hospice residents with total care. The facility currently has 27 residents in care. The facility does not handle any of the residents’ money. Last fire drill was conducted on 4/5/2022. The facility is a two-story residential building located in a residential neighborhood. LPA Campos and Ms. Alcarez, Administrator, toured the facility which consisted of the following: first floor: the facility has a lobby/receptionist/office area, living room, dining room, 8 resident bedrooms, and 8 bathrooms. Second floor: common areas, living room, dining area, 9 resident bedroom, and 9 bathrooms. Front porch/ cover ceiling and (3) tables and (12) chairs, and secondary sitting area with (2) tables, (2) umbrellas, and 10 chairs, large bird cage with 30 birds, and vegetable/ fruit garden, areas used for resident activities; second floor outside patio with (3) tables, (3) umbrellas, and 12 chairs. LPA toured the physical plant with Ms. Alcarez. There were no bodies of water or obstructions on the premises. Rooms #4, #5, #6, #10, #14, and #15 were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured at 118 degrees Fahrenheit. A comfortable temperature of 73 degrees was maintained in the facility. The LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and not accessible to clients. The kitchen was inspected and there is sufficient perishable and non-perishable food available and observed to be maintained properly. First Aid kit was checked and has required items. Fire extinguishers are charged, smoke detectors and carbon monoxide are operable. Fire Drills were observed to be maintained in order and accurate.

Evaluation Report Continues on LIC 809-C

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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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 MANOR BY SERENITY CARE HEALTH
FACILITY NUMBER: 198601877
VISIT DATE: 05/12/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff and residents were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of the report was provided to Administrator Mona Alcarez

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan CamposTELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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