198601877-10-7-2021-11-AS-MCAA-C8GVKT-20211105163051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601877
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:55:12 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
09/07/2021 and conducted by Evaluator Jennifer Jones

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210907153718

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:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Mona Alcarez, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not meet resident's hygiene needs.
Staff did not ensure that resident's injury was cared for.
Facility did not ensure that resident was adequately hydrated.
Facility did not ensure that resident was adequately fed.

INVESTIGATION FINDINGS:

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

On 09/08/21, LPA Jones toured the facility and discussed the allegations with Mona and interviewed 2 residents in care. LPA requested copies of physician report, facility notes of cut of resident's hand, documentation of and bathing schedule.

During today's visit, LPA met with Mona Alcarez and discussed the allegations. LPA interviewed staff 2, 3 and residents 2 and 3. LPA requested copies of the staff and resident rosters.

The allegations revealed the following. For Allegation: (Facility did not meet resident's hygiene needs) It is being alleged that the resident 1 had not been bathed and her skin was dry. LPA interviewed staff 1- 3 about the allegation. The administrator stated that R1 received showers twice a week and provided LPA with a

Unsubstantiated

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: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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-20210907153718

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: 10/07/2021

NARRATIVE

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shower schedule. The administrator stated that the staff gave R1 showers and would give R1 sponge baths in between her shower days. The administrator stated that staff changed R1's clothes everyday. The administrator stated that R1's diaper was changed 3xs a day an R1 never had a foul odor. Staff 2 revealed during her interview that she works on the 2nd floor and only assisted R1 when she came downstairs. Staff 3 revealed during her interview that she assisted resident 1 often. Staff 3 stated that she gave R1 baths twice a week and also gave her sponge baths in between her showers. LPA interviewed resident 2 and 3 and attempted to interview residents 4 and 5. Resident 2 revealed during her interview that she saw R1 often and she appeared to be manicured. Resident 2 stated that she doesn't have any complaints and staff assist her with her hygiene needs. R3 revealed during his interview that he is independent and doesn't needs assistance with ADLs.

For allegation:(Staff did not ensure that resident's injury was cared for.) It is being alleged that R1 had a cut on the top of her left hand that did not seem properly cared for. The administrator revealed during her interview that R1 was agitated, banged her hand on the rail which resulted in a scratch. The administrator stated that staff cleaned up the scratch. Staff 2 revealed during her interview that she doesn't remembering seeing a cut on R1's hand. S3 stated during her interview that she does remember seeing a cut on R1's hand but she doesn't know how she got it. Staff 3 said she was told by another coworker that R1 was agitated one day and scratch her hand. LPA interviewed resident 2 and 3 and attempted to interview residents 4 and 5. Resident 2 said she did not observe a cut on R1's hand and R3 said he doesn't remember R1.
For allegation: (Facility did not ensure that resident was adequately hydrated.) It is being alleged that R1 appeared to be severely dehydrated which caused some dryness of the mouth. The administrator stated that R1 was not dehydrated and R1 received lots of fluids. The administrator stated R1 was retaining a lot of fluids on her own until 08/30/21. The administrator stated on 08/30/21, R1 did not want to drink any fluids on her own so the staff would give them to her to keep her hydrated. The administrator said R1 appeared to be depressed and when the family member came to visit on 09/05/21, R1 did not want to stand up. The administrator stated that she brought R1 out to visit family in a wheelchair. Staff 2 revealed during her interview that R1 was not dehydrated. Staff 2 stated that R1 was fine but on Sunday, 09/05/21, R1 appeared to be weak. Staff 3 revealed during her interview that R1 was not dehydrated. S3 stated that on 09/04/21, R1 stopped eating and drinking. S3 stated that she knew something was wrong because prior to Saturday 09/04/21, R1 retained lots of fluids. S3 stated that R1 like to drink coffee, juice and water. S3 stated that

SUPERVISOR'S NAME: Michael Cava	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jennifer Jones	TELEPHONE: (323) 518-3833
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210907153718

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: 10/07/2021

NARRATIVE

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R1's lips were dry and when she would try to clean them and provide ointment/Vaseline, R1 told her not to touch her lips because they hurt. LPA interviewed resident 2 and 3 and attempted to interview residents 4 and 5. Resident 2 revealed during her interview that she would see R1 in the dining room all of the time. R2 stated that R1 would drink two whole bottles of water and orange juice. R2 said the last time she saw R1 she looked depressed and heard her moaning. R2 stated that she stopped seeing R1 in the dining room. R3 stated that he does not remember seeing R1 but stated that he is able to have something to drink whenever he wants.

For allegation: (Facility did not ensure that resident was adequately fed.) It is being alleged that R1 appeared to not have had food or water for some time. The administrator stated that R1 was a good eater and would feed herself. The administrator stated on 08/30/21, R1 didn't want to feed herself anymore. The administrator stated staff would feed R1 and on 09/05/21, R1 did not want to eat at all. The administrator stated that she contacted R1's family to take her to the ER to see what was wrong. Staff 2 stated that she did not work on 09/04/21 but when she returned on 09/05/21, R1 did not want to eat. Staff 3 stated on 09/05/21, R1 did not want to eat at all and she told the administrator. LPA interviewed resident 2 and 3 and attempted to interview residents 4 and 5. Resident 2 stated that R1 was a good eater and she would see her in the dining room all of the time. Resident 3 stated that he doesn't remember R1 but said he receives breakfast,, lunch and dinner.

LPA reviewed the facility notes regarding R1 and LPA did not find any evidence of neglect. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted and 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: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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