198601877-9-22-2021-11-AS-MCAA-C85TUN-20211025150236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601877
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:26:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/17/2021 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210917085412

FACILITY NAME:	BENTLEY MANOR BY SERENITY CARE HEALTH		FACILITY NUMBER:	198601877
ADMINISTRATOR:	MONA ALCAREZ		FACILITY TYPE:	740
ADDRESS:	3425 MCLAUGHLIN AVE.		TELEPHONE:	(213) 478-0800
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90066
CAPACITY:	27	CENSUS: 15	DATE:	09/22/2021
		UNANNOUNCED	TIME BEGAN:	11:43 AM
MET WITH:	Mona Alcaraz, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Residents are not being accorded privacy while in care.
Residents are not being provided with safe and healthful living accommodations while in care.
Bedroom(s) of resident(s) are being used as a passageway to another room, bath or toilet.
More than two residents are sleeping in a bedroom at the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jennifer Jones conducted an unannounced complaint visit and delivered findings. LPA met with Mona Alcaraz and explained the reason for the visit.

During today's visit, LPA Jones toured the facility and observed rooms #3, #11 and observed door handles in the bedrooms and bathrooms. LPA discussed the allegations with Mona Alcarez. LPA interviewed resident 1 and attempted to interview residents 2-6 about the allegation. LPA requested a copy of the facility fire clearance, facility sketch and resident and staff roster.

The allegations revealed the following: (Residents are not being accorded privacy while in care.) It is being alleged that the facility is not allowing privacy for residents due to two of the rooms being used as a passageway to access the bathroom and exit door. The administrator stated that all of the residents are accorded privacy. The administrator stated that the residents have not complained about their living accommodations. Resident 1 who lives in one of the backrooms revealed during his interview that he

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210917085412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HEALTH	FACILITY NUMBER: 198601877
	VISIT DATE: 09/22/2021

NARRATIVE

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doesn't have a problem with privacy. R1 said they all share a bathroom which was a little challenging but they all have a schedule. R1 stated that he knows the residents and everyone is understanding. LPA attempted to interview residents 2-6 but was unable to get a response due to their diagnosis. Due to residents 2-6 medical diagnosis, LPA was unable to verify if the residents are granted privacy.

For allegation: (Residents are not being provided with safe and healthful living accommodations while in care.) It is being alleged that the facility is not allowing comfortable living accommodations for residents in care. The administrator revealed during her interview that the residents are provided comfortable living accommodations and she hasn't received any complaints. R1 stated that he feels safe and comfortable in his room. LPA attempted to interview residents 2-6 but was unable to get a response due to their diagnosis. Due to residents 2-6 medical diagnosis, LPA was unable to verify if the residents are safe and comfortable.

For allegation: (Bedroom(s) of resident(s) are being used as a passageway to another room, bath or toilet.) It is being alleged that rooms 3 and 11 are used as a passage way to the exit door and bathroom. LPA toured rooms #3 and #11. In room # 3, beds A & B are vacant and beds C & D are filled. Bedroom #11 has beds A, B, C and D and are all filled. Both bedrooms #3 and #11 has a wall with a door that separates beds A & B from beds C & D. Both rooms has a passageway that leads into the other room..

For allegation:(More than two residents are sleeping in a bedroom at the facility.) It is being alleged that 4 residents are occupied in one room. During the tour, LPA observed room #3 and #11. Both rooms have one room number and each room has 4 beds with a dividing wall. The administrator revealed during her interview that the facility received a fire clearance when they were licensed.

Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (8) are being cited on the attached LIC 9099D.

A copy of the report was given to the administrator.

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210917085412

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 HEALTH	FACILITY NUMBER: 198601877
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/08/2021 Section Cited CCR 87464(2)	1 2 3 4 5 6 7	Safe and healthful living accommodations and services. This requirement is not met as evidence by: Based on observation, residents are granted a safe and healthful room due to sharing a room with	1 2 3 4 5 6 7	The administrator will come up with a plan to ensure residents are granted safe and healthful accomodations by not having more than two residents to a room and not using another room as a passageway.
Type B 10/08/2021 Section Cited CCR 87307(a)(2)(C)(D)	1 2 3 4 5 6 7	Resident bedrooms shall be provided which meet, at a minimum, the following requirements: No bedroom of a resident shall be used as a passageway to another room, bath or toilet. Not more than two residents shall sleep in a bedroom. This requirement is not met as evidence by: Based on observation rooms 3 and 11 are divided by walls to separate beds	1 2 3 4 5 6 7	The administrator will come up with a plan that will not allow a passageway to another room and separate the rooms from having one room number with 4 beds.
	8 9 10 11 12 13 14	but its forces residents walk through one room to the other in ordered to be granted access to the bathroom and exit door.	8 9 10 11 12 13 14
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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: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC9099 (FAS) - (06/04)

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