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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601877
Report Date: 09/19/2023
Date Signed: 10/11/2023 03:43:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/15/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210915110614
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:0CENSUS: 0DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:(Facility Closed, effective 08/30/22)TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to provide medical services in a timely manner.
INVESTIGATION FINDINGS:
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On 09/19/23, Licensing Program Analyst (LPA) / Retired Annuitant (RA) Elizabeth Ceniceros rendered the investigation findings (via USPS certified mail) due to the Licensee surrendering the License on 09/15/21. Licensee: Binko Corp. 1142 S. Diamond Bar Blvd, Suite #406, Diamond Bar, CA 91765 is being served with this complaint investigation report via USPS Certified Mail Receipt #7018 1830 0000 6864 2035.

The investigation consisted of an initial 10-Day visit conducted by LPA Jennifer Jones on 09/15/21 and a subsequent visit was conducted on 10/08/21 by LPAs Jennifer Jones and Ngozi Nwaoko who met with Administrator (A1: Mona Alcarez). During the initial 10-Day visit on 09/15/21, LPA Jones requested documentation: Emergency I.D. & Information, Admission Agreement, Physician’s Report, Appraisal/Needs and Services Plan, Hospital Records, and Unusual Incident/Injury reports for Resident #1 (R1). During the subsequent visit on 10/08/21, LPAs Jones and Nwaoko interviewed Staff #2 – Staff #4 and R1’s family member (via telephone). On 10/12/21, LPA Jones interviewed Staff #5 (via telephone). A separate investigation was conducted by Department of Social Services Investigator Dennis Douglas.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 11-AS-20210915110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY MANOR BY SERENITY CARE HEALTH
FACILITY NUMBER: 198601877
VISIT DATE: 09/19/2023
NARRATIVE
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Regarding Allegation #2: this investigation revealed that Resident #1 sustained an unwitnessed fall in their room on the morning of 09/13/21; whereby Resident #1 was discovered on the floor by Staff #3 (Caregiver). Staff members assessed Resident #1 at that time and did not observe visible injuries. Resident #1 did not complain of pain and declined emergency medical services to Staff #3. Staff #5 (Caregiver) checked on Resident #1 at 6:45 a.m. (before end of shift) and Resident #1 was still sleeping. Staff #4 (Caregiver) observed Resident #1 watching T.V. Staff #3 stated that R1 was able to move around on their own and used a walker for assistance. Staff #3 checked on R1 around 7:30 a.m. and the resident was still in bed. Staff #3 went back to R1's room (approximately) 8:30 a.m. and found R1 on the floor in a sitting position; but, R1 had not expressed pain. Staff #3 stated as R1 was trying to get up on their own, S3 told R1 not to move because facility staff was calling 9-1-1. Staff #3 stated facility staff helped R1 off the floor and assisted them to the bathroom. Staff #3 stated that R1 had breakfast and lunch with no problem; however, after lunch, R1 complained about chest pain and shortness of breath and facility staff immediately called 9-1-1. Administrator confirmed that R1 had breakfast and lunch that day and did not complain about shortness of breath until 1:00 p.m. After R1 began to complain of having chest pain and shortness of breath, facility staff called 9-1-1 and the resident was transported to St. John Hospital. Once at the hospital, it was discovered that Resident #1 had sustained multiple rib fractures. Administrator stated that R1 was not a fall risk. [A review of the Physician's Report (dated 07/26/21) does not document that R1 is a fall risk. A review of the Pre-placement Appraisal Information (dated 07/20/21) documents "can stand up and walk w/assistance (walker)."] On 09/15/21, Resident #1 was transferred to Rehab Center of Santa Monica for physical therapy/ occupational therapy needs; however, the resident caught pneumonia. The medical report indicated that the multiple “unhealed” left rib fractures and right rib fractures were chronic. Resident #1 ultimately passed away on 09/19/21 while in the medical care at the Rehab Center of Santa Monica.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/ LACK OF SUPERVISION: Facility failed to provide medical services in a timely manner is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed and citation issued (ref. LIC 9099D). Civil Penalty assessed.

No exit interview conducted as the facility closed its doors, effective 08/30/22. This complaint investigation report will be sent to Licensee (via USPS Certified Mail Receipt #7018 1830 0000 6864 2035).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20210915110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2023
Section Cited
CCR
87465(g)
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87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidence by:
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Licensee/Administrator shall read Title 22, Section "Incidental Medical and Dental Care" and send a written statement to CCLD by the POC date that they will ensure to stay in constant communication with the medical professional and if the resident's medical condition elevates; meaning they require a
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(Cont) Facility failed to call 9-1-1 in a timely manner when Resident #1 sustained a fall in the resident’s room and was found by Staff #3 (Caregiver) on the floor – only an assessment was conducted at the time of the resident's fall.
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(Cont) higher level of care, they will ensure the resident receives medical services in a timely manner. Because facility staff failed to call 9-1-1 in a timely manner which resulted in the resident being diagnosed with multiple right rib fractures, civil penalties are assessed in the amount of Five-hundred Dollars ($500). The POC is due to the CCLD/El Segundo ASC Office by 09/26/23.
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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 HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
09/15/2021 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20210915110614

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:0CENSUS: 0DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Facility Closed effective 08/30/22TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained fractured ribs while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/19/23, Licensing Program Analyst (LPA) / Retired Annuitant (RA) Elizabeth Ceniceros rendered the investigation findings (via USPS certified mail) due to the Licensee surrendering the License on 09/15/21. Licensee: Binko Corp. 1142 S. Diamond Bar Blvd, Suite #406, Diamond Bar, CA 91765 is being served with this complaint investigation report via USPS Certified Mail Receipt #7018 1830 0000 6864 2035.

The investigation consisted of an initial 10-Day visit conducted by LPA Jennifer Jones on 09/15/21 and a subsequent visit was conducted on 10/08/21 by LPAs Jennifer Jones and Ngozi Nwaoko who met with Administrator (A1: Mona Alcarez). During the initial 10-Day visit on 09/15/21, LPA Jones requested documentation: Emergency I.D. & Information, Admission Agreement, Physician’s Report, Appraisal/Needs and Services Plan, Hospital Records, and Unusual Incident/Injury reports for Resident #1 (R1). During the subsequent visit on 10/08/21, LPAs Jones and Nwaoko interviewed Staff #2 – Staff #4 and R1’s family member (via telephone). On 10/12/21, LPA Jones interviewed Staff #5 (via telephone). A separate investigation was conducted by Department of Social Services Investigator Dennis Douglas.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20210915110614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BENTLEY MANOR BY SERENITY CARE HEALTH
FACILITY NUMBER: 198601877
VISIT DATE: 09/19/2023
NARRATIVE
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Regarding Allegation #1: this investigation revealed based on interviews conducted of facility staff members, the majority corroborated that Resident #1 indeed sustained an unwitnessed fall in the resident’s room at the facility on the morning of 09/13/21. Staff members assessed R1 at that time and did not observe visible injuries. Resident #1 did not complain of pain and declined emergency medical services to facility staff. Later that day (approximately 1:00 p.m.), Resident #1 complained of chest pain and shortness of breath and was transported to St. John Hospital. Once at the hospital, it was discovered that Resident #1 had multiple rib fractures. Administrator stated after R1 began to complain of having chest pain and shortness of breath, facility staff called 9-1-1 and R1 was transported to St. John Hospital. Once at the hospital, it was discovered that Resident #1 had sustained multiple rib fractures. Administrator stated that R1 was not a fall risk. [A review of the Physician's Report (dated 07/26/21) does not document that R1 is a fall risk. A review of the Pre-placement Appraisal Information (dated 07/20/21) documents "can stand up and walk w/assistance (walker)."] The medical report indicated that the multiple “unhealed” left rib fractures and multiple right rib fractures sustained by Resident #1 were chronic. On 09/15/21, Resident #1 was transferred to Rehab Center of Santa Monica for physical therapy/occupational therapy needs. Resident #1 ultimately passed away on 09/19/21 while in the medical care at the Rehab Center of Santa Monica. Witnesses interviewed corroborated that the facility was not at fault or suspected neglect towards R1. Witnesses did not have the death certificate but were told that R1 passed away due to a condition not associated to R1's fall.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Resident sustained fractured ribs while in care is found to be UNSUBSTANTIATED.

No exit interview conducted as the facility closed its doors, effective 08/30/22. This complaint investigation report will be sent to Licensee (via USPS Certified Mail Receipt #7018 1830 0000 6864 2035).

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5