Bentley House

Type of visit: Required - 1 Year

On 8/11/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Lilybelle Calzado/Lead Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory residents ages 60 and above of which (1) may be bed-ridden. Facility has an approved hospice waiver for (3) patients. Now facility has 5 residents. Facility has 6 resident bedrooms, 6 bathrooms, a front den / sitting area, attached garage, dining room, living room, back shaded patio. The resident’s bedrooms are spacious and easily accommodate their furnishings. There is a patio area and chairs. Shaded area has sufficient tables and chairs for clients and staff. LPA Iniguez toured the physical plant with staff. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3 and smoke and carbon monoxide combo are all operable conditions. The water temperature properly measured between 105°-120°F: Kitchen 107.9°F, Bathroom #1:107.5°F, Bathroom #2:106.6°F and Bathroom #3:107.9°F Evaluation Report Continues LIC 809-C LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, sharps objects and cleaning supplies were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. A review of (3) residents' service files, (3) staff personnel files and (3) Centrally Stored Medication and Destruction Record (CSMD) were maintained in order. First AID kit was checked. LPA observed the facility's infection control practices. Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Lilybelle Calzado/Lead Staff.the state’s words, verbatim · CDSS document, Aug 11, 2023

Allegation investigated: Licensee had liability insurance that did not include required coverage for resident’s injuries. The Licensee has no current liability insurance.

This unannounced subsequent complaint inspection is being conducted by Licensing Program Analyst (LPA) Jose Calderon for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA Jose Calderon met with Staff Lilybelle Calzado and explained the reason for today’s inspection. There was concern that the Licensee representative had liability insurance that did not include the required coverage for resident’s injuries. On 12/13/2022, LPA Jose Calderon conducted the initial 10-day complaint investigation and conducted interviews from 9:30 a.m. to 2:30 p.m., along with reviewing and/or obtaining copies of the resident roster, staff roster and insurance records. Facility staff stated that this facility had liability insurance with an effective date of 08/26/2022. Further investigation was required. Substantiated On 12/14/2022 the LPA Jose Calderon reviewed the insurance records for clarification. Licensee presented multiple Certificate of Liability Insurance. The Certificate of Liability Insurance dated 09/02/2022 for Policy Number ending in 191-0 shows an effective date of 08/26/2022 thru ending date of 8/26/2023. This corroborates with the facility staff’s statement. This certificate indicates the coverage of limits one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. However, this certificate states that this policy is shared by this facility and six (6) other facilities, meaning this policy does not provide the required coverage of one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate for this facility. On 12/6/2022, the Policy Number ending in 191-0 dated 9/2/2022 was rewritten into Policy Number ending in Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] and there was no gap between these policies since 08/26/2022 thru ending date of policy of 8/26/23. This is a separate, stand-alone business liability insurance for this facility. An Insurance Binder dated 12/08/2022 for Policy Number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] identified multiple policy exclusions, including exclusions for “Infestation”, “Bedsores”, “Elopement (General Liability)”, and “Treatment of Coronavirus”. Per witness interview, the exclusion for “Bedsores” means that this policy does not cover resident injuries due to bedsores if there is evidence of negligence on the part of the Licensee. Witnesses also stated that the exclusions for “Infestation” and “Elopement (General Liability)” mean that the Licensee is not responsible for obtaining insurance for injuries to residents from infestations and elopements. Due to the exclusions, this policy does not include the required coverage for resident injuries caused by the negligent acts or omissions to act of, or neglect by, the Licensee or its employees. The Certificate of Liability Insurance dated 12/13/2022 for policy number ending in [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] shows an effective date of 12/06/2022. While the Licensee had insurance policies in place from 08/26/2022, the policies [Bentley Suites: 493-0; Henrietta’s Leven Oaks: 499-0; Kaego’s Richman Gardens: 501-0; Bentley House: 496-0; Bentley Manor: 498-0; Bentley Hills: 492-0; Henrietta’s Home: 500-0] did not provide the required coverage due to the exclusions they contained; and, because this facility was sharing a single policy with six (6) other facilities (Bentley Suites 198320302; Henrietta's Leven Oaks 198603586; Kaego's Richman Gardens 306006189; Bentley House 198320303; Bentley Manor 198320301; Bentley Hills 195850277; Henrietta's Home 198603585). Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, this facility did not have its own liability insurance coverage that is compliant with Title 22 Regulations, and licensee has no current liability insurance. As a result, the above-mentioned allegations are being substantiated. Please see LIC9099D for cited deficiencies per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, May 17, 2023 · control 11-AS-20221212120312

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: May 24, 2023

HSC 1569.605 –Liability insurance… all residential care facilities for the elderly … 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. This requirement was not met as evidenced by: Based on liability insurance records reviewed, interviews conducted with Administrator and relevant witnesses, it was determined that the licensee did not have required liability insurance coverage for 08/26/2022 to present which poses an immediate safety risk to residents in care. Based on interviews and records review, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts specified which posed a potential Health, Safety, or Personal Rights risk to 4 persons in care.the state’s words, verbatim · CDSS document, May 17, 2023

Plan of correction: Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA Calderonn by POC due date (05/24/23).

Type of visit: Post Licensing

On 12/13/2022 at 11:00 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced Post licensee inspection visit at the Bentley House Facility. LPA Calderon was allowed entry into the facility by Staff Lilybelle Calzado. Staff Calzado asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) adult clients with developmental disabilities. Currently, there are (4) residents residing in the facility with developmental disabilities. LPA Calderon explained to Staff Lilybelle Calzado, the purpose of the Post licensee Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: (3) resident service records, (3) resident medication records, (3) staff records, and inspected the inside facility and outside grounds. The facilities’ last fire drill was conducted on 10/04/2022. The one-story residential home consists of (6) resident bedrooms, (6) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water supply is found in the garage. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 105 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 108 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 109 degrees Fahrenheit, and bathroom #4 hot water temperature properly measured at 112 degrees Fahrenheit. Bathroom #5 hot water temperature properly measured at 111 degrees Fahrenheit, and bathroom #6 hot water temperature properly measured at 112 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (1) carbon Monoxide and (7) Smoke Detectors hard wired and connected were tested and are working properly. The facility (3) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. Three (3) resident files were reviewed and found to be complete. LPA Calderon reviewed (3) resident medications and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Mona M Alcaraz Certification # 6031257740 expiration date of 06/04/2024 was valid at time of visit. The facility does NOT handle resident's money/cash resources and a Surety bond is not needed at this time. All the required documents are posted in the facility in a clearly visible area to include a copy of the General Liability policy which the facility could NOT produce a valid policy at time of inspection. LIC500 all 8 staff members are associated to the facility. LPA Calderon requested a copy of the LIC308 dated 12/13/2022, designate name Lilybelle Calzado. During the visit, LPA Calderon observed the physical plant & environment safety practices. LPA Calderon observed screening protocols for visitors, staff and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day supply of Personal Protective Equipment (PPE). LPA Calderon advised the Staff Calzado to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe NO deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Staff Lilybelle Calzado.the state’s words, verbatim · CDSS document, Dec 13, 2022

Allegation investigated: Facility staff stole residents belongings. Facility staff is withholding residents mail.

On 11/14/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced visit to the facility and was greeted by lead caregiver Lilybelle Calzado staff #1 (S1). LPA explained the purpose of this visit is to investigate the allegations mentioned above. The investigation consisted of the following: LPA initiated an investigation for the above-mentioned allegations. Interviews with staff #1-#4 (S1-S4), resident #1-#6 (R1-R5) and witness #1 (W1). LPA requested copies of the following: staff and resident rosters, (R1’s) physician’s report, appraisal/needs and services plan and other documents associated with this complaint. Evaluation Report continues LIC 9099-C Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Facility staff stole residents belongings. Facility staff is withholding residents mail. The details of the complaint state resident #1 (R1's) personal belongings were stolen and that mail is being withheld by staff. The complainant claims the facility stole (R1's) vitamins/supplements and prescription medications. (R1) was a resident at this facility from 08/12/21 through 10/20/22. As of 10/21/22, (R1) is now a former resident and no longer resident at this facility. The Department interviewed (R1) who currently resides at a skilled nursing facility (SNF) who stated not receiving all vitamins/supplements as well as prescribed medications during the transition. (R1) stated during the move, (R1) was not involved in with process and did not observe what belongings were packed, stored, or transported. (R1) was not certain if the personal belongings were stolen by staff. (R1) stated, "it was not a malicious act". Interviews with staff #1 - #3 (S1-S3) dispute this claim. (S1-S3) stated (R1) self-medicated and stored all medications including vitamins/supplements to prevent staff from accessing them. (S1-S3) reported (R1) was present throughout the entire transition process. Caregiver staff #3 (S3) reported (R1), observed, and directed what belonging would be packed, stored, and moved. (S1-S3) reported there were about 30 boxes that were stored in personal storage leased by (R1). According to (S2-S3), (R1) was limited on what personal items were allowed at the (SNF) and left some bags of vitamins/supplements in storage and several bags went with (R1) to SNF. (S1-S2) had an agreement signed by (R1) dated 10/19/22 stated the following prescribed medications: Loperamide, Capecitabine, Ondansetron, and Cal-Gest Antacid were in possession with (R1) when she left the facility on 10/20/22. An interview with the social worker (W1) at the (SNF) verified that (R1) was admitted with vitamins/supplements. (R1) did not have any prescribed medications when (R1) was admitted on 10/20/22. Interviews with residents #2-#5 (R2-R5) were complimentary of staff. (R2-R5) stated they had no concerns over their belongings and it is safeguarded by staff. The complainant alleges the staff has withheld (R1's) mail. An interview with (R1) revealed that a change of address has been implemented with USPS. (R1) claims she did not get to vote during the November election due to no ballot was sent to the new address. An interview with administrator Mona Alcaraz stated (R1) had a verbal agreement that once (R1) is settled at (SNF), Evaluation Report continues LIC 9099C (R1) will call the facility to determine how the mail shall be forwarded. (S2) claims (R1) has not reached out to her and that eight (8) mail items are held. There was no evidence of a 2022 US Ballot held at the facility. Interviews with (R2-R5) stated no issues with personal mail as family members would bring them over during each visit to the facility. Due to a health condition, resident #6 (R6) was unable to hold a conversation and did not participate in an interview. Based on the information gathered, an inspection of the facility, observation, analysis of (R1's) service records, photographs, videos, written agreements, and interviews conducted, the Department found no evidence to support the allegations mentioned in this complaint Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated. No deficiencies were cited during this visit. An exit interview was conducted with Lilybelle Calzado, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 14, 2022 · control 11-AS-20221108111748

Allegation investigated: Staff did not safeguard resident's personal property. Staff are not meeting residents needs.

On 11/4/22 Licensing Program Analyst (LPA) Don Senaha initiated a subsequent complaint investigation for the allegations listed above to deliver findings. Today’s complaint investigation was conducted at the facility with Lead caregiver Lilybelle Calzado. On 09/21/2022 Licensing Program Analyst (LPA) Don Senaha initiated an initial complaint investigation for the allegations listed above. Today’s complaint investigation was conducted at the facility with Lead caregiver Lilybelle Calzado. LPA interviewed clients (R1-R4). Resident (R5) was unable to interview at the time. LPA interviewed staff (S2-S3) and staff (S1) the Licensee on the phone. LPA obtained pertinent documents. A plant inspection of the facility was conducted during both visits. No deficiencies were found at the time of the visit. Unsubstantiated Investigation revealed: Allegation: Staff did not safeguard resident’s personal property During the course of investigation, LPA was unable to find any evidence supporting the allegation. Three (3) of the four (4) residents interviewed stated staff has access to their room when residents are not present but have no issues with staff entering their rooms. Three (3) of the four (4) residents stated there are no issues with belongings or personal property missing from resident’s rooms. Administrator stated there are no reports of missing personal property from resident’s rooms. Staff (S2-S3) stated residents four (4) of the five (5) residents have not claimed missing personal property from resident’s room. Staff (S3) stated staff does not go into resident (R1) room to clean unless (R1) is present per (R1) request. Staff (S3) stated staff closes (R1) door and does not enter the room until (R1) is present when (R1) leaves the facility. LPA observed resident (R1) room to be crowded with boxes of various items open and unopened during visit. There is no evidence that supports the allegation the facility does not safeguard resident’s personal property. Allegation: Staff are not meeting residents needs. During the course of investigation, LPA was unable to find any evidence supporting the allegation. Three (3) of the four (4) residents interviewed stated there are no issues with staff not meeting resident’s needs. Three (3) of the four (4) residents interviewed stated to call for staff assistance the residents push the call button or call staff’s name. Three (3) of the four (4) residents interviewed stated there are no issues with response from staff when calling for help. Administrator stated residents have the call button to get assistance. Administrator stated staff responds immediately to the call button. Administrator stated mobility devices are within reach of the residents. Staff (S2-S3) stated residents push the call button for assistance. Staff (S2-S3) stated staff responds immediately to call button unless staff is assisting another resident. Staff will notify available staff to assist. Staff (S2-S3) stated mobility devices are within reach of the residents. LPA observed no issues with the positioning of mobility devices in resident’s rooms at the time of the visit. LPA observed these mobility devices to be in reach of each resident in resident’s rooms. LPA observed the call button being responded to by staff several times during the investigation at the facility. There is no evidence that supports the allegation the staff are not meeting residents needs. Based on LPA’s interviews conducted and records reviews, the preponderance of evidence standard has not been met. 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 allegations are Unsubstantiated. An exit interview was conducted with Lead caregiver Lilybelle Calzado and a hard copy was provided.the state’s words, verbatim · CDSS document, Nov 4, 2022 · control 11-AS-20220915154115

Allegation investigated: Facility staff failed to follow physicians orders

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on Tuesday, August 23, 2022. Upon arrival at the facility. LPA Bunker called the facility via telephone and conducted a Risk Assessment. Based on the assessment, the facility is cleared of COVID-19 infection. LPA Bunker met with staff Lily Belle Calzado. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews conducted with staff 1-2 (S1-S2) and residents (R2-R4) stated staff is following the physician's orders. Residents 5-6 (R5-R6) were sleeping and is on hospice. R1 stated she is handling her own medication. LPA Bunker was unable to interview R5-R-6. S1-S2 stated that R1 was prescribed a new medication by her doctor. Staff stated they are providing R1 with a meal 30 minutes before taking her medication. S1-S2 stated they did not fail to follow the doctor's order. See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 Allegation: Facility staff failed to follow physicians orders Staff 1-2 (S1-S2) and residents (R2-R4) stated staff is following the doctor's orders. S1-S2 stated that R1 was prescribed a new medication by her doctor. S1-S2 stated they are providing R1 with a meal 30 minutes before taking her medication. S1-S2 stated they are not failing to follow the doctor's order. S1-S2 stated they provided R1 with food before taking the medication. S1-S3 stated that R1 is not having any huge side effects. S1-S2 stated R1 will complain about everything. S1-S2 stated R1 want staff to stop assisting other R1 and assist her immediately. S1-S2 stated staff is providing residents with the necessary care and supervision to meet the resident's needs and services as specified according to their physician's directions. Investigation revealed the following: S1-S2 stated that once ordered by the physician the medication is given according to the physician's directions to all residents. However, R1 refused to allow staff to dispense medication. S1-S2 stated R1 was given a new medication for 2 weeks. S1-S2 stated that R1 is provided food before taking her medication. S1-S2 stated on August 05, 2022, R1 provided staff with a written notice stating beginning Saturday, August 06, 2022, she will administer her medication and doesn’t need any assistance from the facility staff. R1 stated she is handing her medication. R1 stated she fell asleep, forgot to set her timer, staff did not wake her up, and she didn't take her medication at the required time. R1 stated she did not have any side effects from taking the medication later. R2-R4 stated staff is following their doctor's orders. LPA Bunker was unable to interview residents 5-6 (R5-R6) they were asleep and is on hospice. S1-S2 stated the allegation is false and they are following the doctor's orders. S1-S2 denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed unsubstantiated. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Aug 23, 2022 · control 11-AS-20220815165657

Type of visit: Case Management - Other

8/11/2022 at 1:00pm Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced Case Management visit to the Bentley House. LPA explained the purpose of the visit was to speak with one of the residents and was allowed entry. LPA Cifuentes spoke with resident 1(R1) and provided them with information. No deficiencies were assessed during this visit. An exit interview was conducted with Staff Lilybelle Calzado and a hard copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 11, 2022

Type of visit: Case Management - Other

On 7/26/2022 Licensing Program Analyst (LPA), Stephanie Cifuentes conducted an unannounced follow-up inspection to the above facility for purpose of following up on the plan of correction issued during the change of ownership pre-licensing evaluation completed on 7/25/2022. LPA observed the following on 7/26/2022 -Outside activity area is properly enclosed with self-closing latches on gate. -Outside activity area has 6 chairs, 4 around table and 2 under awning. All plans of correction have been cleared. Exit interview conducted with Administrator Mona Alcaraz and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2022

Type of visit: Prelicensing

On 7/25/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes and Perry Scott conducted an announced continuation inspection to the above facility for the purpose of a change of ownership pre-licensing evaluation. An application was submitted to Community Care Licensing Department(CCLD) on 04/23/2022, for a Change of Ownership for a Residential Care for the Elderly. The requested capacity is for 6 clients, 5 non-ambulatory, 1 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Bedrooms Residents: LPA’s observed 6 resident bedrooms, 5 bedrooms are for non-ambulatory and 1 bedroom is for bedridden. Bedrooms 1, 2, 3, 4, 5 and 6, have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. Drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Bathroom: Facility has 6 client bathrooms. Bathrooms have working toilets, wash basins and showers. There are grab rails next to both the toilets and the showers as well as nonskid mats in showers. LPA observed adequate lighting in hallway leading to bathrooms. Emergency Phone Numbers, Exit Plan & Menu: The facility has a landline which was called by LPA and is operational. Emergency Disaster Plan posted & readily available for review on the wall. Two fully charged fire extinguishers were found, one in kitchen and one in dining room. Toxins: Toxins locked/stored in hall cupboard and under kitchen sink. Water temperature: Water temperature in kitchen and bathrooms measured between 123F to 143F. Continued on 809-C Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are in kitchen drawers. Food supply was adequate and stored in kitchen refrigerator and cabinets and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Smoke Detectors: Eight (8) smoke detectors are hardwired and interconnected. 3 carbon monoxide detectors were found in dining room, kitchen and hallway to client rooms. They were tested and are fully operational. Appliances: Stove burners and oven are in good working condition. There is 1 refrigerator in the kitchen. Refrigerator and freezer are at the correct temperature for food storage. Medications, First-Aid Kit & Book: First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients. Clients & Staff Files: Applicant will not be handling cash resources of clients. Records of staff and clients are stored in cabinets near staff desk. Reading Material, Games, Equipment & Materials: The facility has an activity calendar and provides puzzles and other games and papercrafts as well as ball toss. Doors have auditory devices to monitor exits. Pool/Jacuzzi & Pets: LPA's did not observe any pets or bodies of water at the facility. Continued on 809-C Fire clearance: Fire Clearance was approved on 6/17/2022 for 1 bedridden client and 5 non-ambulatory clients. LPA did not observe pad locks or other mechanisms which may be obstructions for safe and quick egress during an emergency on side gates and front exits. Component III: Conducted at the Pre-Licensing visit, on 7/22/2022 at Bentley Manor, information provided about how to operate the facility within substantial compliance. The following corrections need to be completed before licensure: -Outside activity area is not properly enclosed with self-closing latches -Outside activity area has four chair and there should by 6. An exit interview was conducted, and a printed copy of this report was given to the applicant to the applicant. Accordingly, LPA Stephanie Cifuentes will submit a copy of this facility evaluation report to the Central Applicationsthe state’s words, verbatim · CDSS document, Jul 25, 2022

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 7/22/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes conducted an announced inspection to the above facility for purpose of a change of ownership pre-licensing evaluation. An application was submitted to Community Care Licensing Department(CCLD) on 04/23/2022, for a Change of Ownership for a Residential Care for the Elderly. The requested capacity is for 6 clients, 5 non-ambulatory, 1 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Structure: The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) bedrooms, (6) bathrooms, living room, family/ dining room, kitchen, garage/ storage and front porch and covered backyard patio area. There is an apartment on the second floor that is rented out to a tenant. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded back yard with a covered patio, tables and chairs. Outdoor passageways, walkways, driveways, steps and patios are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcases, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen and hygiene supplies stored in hallways cupboards. Due to time constraints LPA could not complete pre-licensing, LPA will return at a later date. An exit interview was conducted with Mona Alcaraz, Administrator and a hard copy was provided.the state’s words, verbatim · CDSS document, Jul 22, 2022

Type of visit: Office

COMP II by CAB successfully completed Facility Type: RCFE Application Type: Profit Corp Capacity: 6 Census (if any clients in care): 6 Method: Telephone at CAB COMP II Participants: Mona Alcaraz (Applicant/Administrator) Applicant/Administrator participated in COMP II at CAB via telephone with analyst at CAB. Identification of the Applicant and Administrator was verified by providing California Driver License number. During COMP II, Applicant and Administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property In addition, Applicant/Administrator acknowledged the full understanding of the questions below: 1. Do you know what an excluded individual means? It means, you cannot have any excluded individual in or working for your facility. Mona Alcaraz replied, “Yes, I understand”. 2. Do you know that Bioseh is lifetime excluded? Meaning he/she cannot have any part of your facility operations nor can he/she be around or in the facility nor have any contact with facility clients. Mona Alcaraz replied, “Yes, I understand”. 3. Do you understand that if you have any excluded persons as part of your facility or present in your facility that you can be cited for noncompliance, fined and have your license revoked? Mona Alcaraz replied, “Yes, I understand”.the state’s words, verbatim · CDSS document, Jul 18, 2022