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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:08:01 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:
09/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mona Alcarez, Administrator TIME COMPLETED:
01:30 PM
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On 09/08/21, Licensing Program Analyst (LPAs) Jennifer Jones, Stephanie Cifuentes, Licensing Program Manager (LPM) Eva Alvarez, Long Term Care Ombudsmen (LTCO) conducted an unannounced Case Management joint visit to the above facility to meet with residents. LPA met with Mona Alcarez, Administrator and explained the purpose of the visit is to meet with resident and provide copies of Decision and Order as well as Accusation in relation to October 29, 2021 facility closure.

Upon arrival, LPA Jones conducted a Health & Safety tour of the facility.

During today's visit, residents were informed of planned closure and provided the Accusation Decision and Order. LPA Jones asked about the liability insurance coverage and was advised by Mona Alcarez that the corporate office is still handling the liability issue coverage and was unable to provide LPA documentation. LPA Jones followed on the requested copies of Admission Agreements from 08/30/21. Mona Alcarez is still working on the admission agreement copies.

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 An exit meeting was held and a copy of the report was given to Administrator, Mona Alcarez. The administrator decline to sign the report.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer JonesTELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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