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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 08/03/2022
Date Signed: 08/03/2022 02:23:47 PM


Document Has Been Signed on 08/03/2022 02:23 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: 23DATE:
08/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:44 PM
MET WITH:Ma Sheila Auingan - StaffTIME COMPLETED:
02:35 PM
NARRATIVE
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On 8/3/2022, Licensing Program Analyst (LPA) Stephanie Cifuentes conducted a case management visit at this facility. LPA met with staff Ma Sheila Auingan 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 and again on 7/26/2022 and 8/3/2022 LPA CIfuentes observed live cockroaches in the kitchen.

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 Ma Sheila Auingan
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Stephanie CifuentesTELEPHONE: (661) 644-7763
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
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 2


Document Has Been Signed on 08/03/2022 02:23 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2022
Section Cited

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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
This requirement is not met as evidenced by
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Based on observation, at 1:30pm LPA Cifuentes observed pests in facility kitchen. This is a potential health and safety risk for the clients 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: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2