<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 08/20/2021
Date Signed: 08/20/2021 10:59:46 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 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: 18DATE:
08/20/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Eden Delespiritusanto, CaregiverTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced Plan of Correction (POC) visit to this facility Bentley Manor By Serenity Care Health. LPA arrived and met with Caregiver Eden Delespititusanto. LPA explained the reason for the visit.

LPA toured the facility and followed up on the POC that was issued on 08/18/2021. Based on record review, the facility failed to meet the POC and still out of compliance.

Civil penalties are being assessed under
HEALTH & SAFETY CODE 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS.

A copy of the report is being issued



SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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 1