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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601877
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:54:15 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: 12DATE:
12/21/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mona Alcarez TIME COMPLETED:
01:00 PM
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On 12/21/21 Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced Plan Of Correction (POC) visit. Upon arrival, LPA was greeted by Administrator Mona Alcarez, and LPA discussed the purpose of today's visit.

During today's visit, LPA Jordan followed up on citation that was issued during a previous visit. The administrator provided LPA with a copy of Liability insurance for the facility. The copy of the policy provided, has the same policy number for facility Bentley House #198601591 Located at 3449 Rosewood Ave Los Angeles Ca 90066. LPA explained to administrator, that multiple facilities cannot share the same policy or be combined. #198601877 BENTLEY MANOR BY SERENITY CARE HEALTH and #198601591 BENTLEY HOUSE are reflecting the same policy number, on copies of certificates provided for proof of liability insurance to Licensing.

Pursuant to Health Safety code: 1569.605 Liability insurance; coverage requirement;
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.

The facility failed to meet this requirement and is still not incompliance.

Civil Penalties are being assessed: 1569.605 Liability insurance; coverage requirement;

Exit interview conducted:
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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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