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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 07/26/2022
Date Signed: 07/26/2022 02:08:23 PM


Document Has Been Signed on 07/26/2022 02:08 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
MONTERY 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: 21DATE:
07/26/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Mona AlcarazTIME COMPLETED:
02:15 PM
NARRATIVE
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On 07/26/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a case management visit at this facility. LPA's met with administrator Mona Alcaraz and explained the purpose of today’s visit is to issue a citation.

During pre-licensing inspection for a change of ownership on 7/22/2022 , LPA CIfuentes observed bed in rooms 1, 3, 4, 5, 6, 9, 10, 11, 13, 14, 15 and 17 had half bed rails. LPA spoke to Administrator, who was able to provide written orders for physicians for rooms 4, 10, 11, and 14. LPA reviewed facility files and did not find written orders for physicians for any of the other residents. LPA was informed by Administrator Mona Alcaraz that facility did not have written orders for other residents.

Deficiencies cited under the California Code Regulations (CCR) Title 22, chapter 6 on attached 809-D.

An exit interview was conducted and a copy of this report and appeal rights were provided to staff Mona Alcaraz.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
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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Document Has Been Signed on 07/26/2022 02:08 PM - It Cannot Be Edited

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
MONTERY PARK, CA 91754


FACILITY NAME: BENTLEY MANOR BY SERENITY CARE HEALTH

FACILITY NUMBER: 198601877

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/09/2022
Section Cited

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Postural Supports
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:

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ON 7/22/2022 LPA Cifuentes observed that beds in rooms 6, 5, 3, 1, 9, 2, 13, 17 and 15 had half bed rails and no writeen orders from physician were in residents record, nor could staff provide copies. This is a potential healtha nd safety risk for 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022
LIC809 (FAS) - (06/04)
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