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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 08/30/2021
Date Signed: 08/30/2021 12:29:57 PM

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:
08/30/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mona Alcarez, Administrator TIME COMPLETED:
12:30 PM
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On 08/30/21, Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced Case Management- Legal/Plan of Corrections visit to the above facility regarding deficiencies issued on 08/19/21. LPA met with Mona Alcarez, Administrator and explained the purpose of the visit.

During today’s visit, LPA Jones toured the facility. LPA Jones asked about the liability insurance coverage and was advised that the corporate office is still handling the liability issue coverage and Mona Alcarez, Administrator was unable to provide LPA with documentation. During the visit, LPA Jones requested copies of resident Emergency ID, staff and resident rosters, admission agreements, physician reports and a medication log.

The facility failed to comply with the POC that was issued on 08/19/21. Additional citations are being issued under regulation. 1569.605 LIABILITY INSURANCE; COVERAGE REQUIREMENTS. On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.




Civil Penalties assessed and an exit interview was conducted. “The Adminisrator was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.”
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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