Bentley Manor

Allegation investigated: Licensee had liability insurance that did not include required coverage for resident’s injuries.

***This amended report supersedes the report dated 5/17/2023. This report is being created to remove substantiated allegation “The Licensee has no current liability insurance” to unsubstantiated. All other complaint report aspects remain in effect. This unannounced subsequent complaint inspection is being conducted by Licensing Program Analysts (LPAs) Ernand Dabuet and Regina Cloyd for the purpose of delivering findings for the investigation into the above identified complaint allegation. The LPAs met with facility administrator Mona Alcaraz 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, and that the Licensee representative has no current liability insurance. Evaluation Report continues LIC 9099-C Substantiated On 12/13/2022, LPA Dabuet conducted the initial 10-day complaint investigation and conducted interviews from 9:35 a.m. to 3:08 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. Based on the investigation conducted by the Department it was determined that between 08/26/2022 and 12/06/2022, Licensee had liability insurance that did not include required coverage for resident’s injuries. As a result, the above-mentioned allegation is 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. Interviews conducted with facility staff and witnesses revealed that facility was actively working with multiple insurance agencies to finalize the policy to comply with Title 22 Regulations. Based on review of the policies submitted to the Department between 08/26/2022 and 12/06/2022 there is insufficient information to support the allegations mentioned above. 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, Aug 24, 2023 · control 11-AS-20221212123347

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Aug 25, 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 12/06/22 which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 24, 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 by POC due date (08/25/23).

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 Mona Alcaraz/Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (27) non-ambulatory elderly adults ages 60 and above of which (5) may be bed ridden. Approved hospice waiver for (8) on rooms: 3#A, 3B, #C, 3D, 4A, and 6 are cleared for bedridden. Currently the facility has (26) residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: (17) resident's rooms with a bathroom in each room, a living area, a dining area, a kitchen, and an outside patio area with umbrellas. LPA Iniguez toured the physical plant with director. There were no bodies of water or obstructions on the premises. A total of (6) 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: and call buttons, and smoke and carbon monoxide are all operable conditions. The water temperature ranged from 108.5F° – 114.2F°. The room temperature ranged from 76F° – 78F°. Evaluation Report continues on 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, cleaning supplies, toxins, and sharps objects 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. The last Fire/Disaster Drills were conducted on 07/10/23. Annual fire clearance performed 7/25/23 and Fire Kitchen inspection conducted on 7/25/23. Working landline phones are available on-site. A review of (4) residents' service files (R1-R4) and (4) staff personnel files (S1-S4) and Centrally Stored Medication Destruction Record (CSMDR) were maintained in order. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings. All mandated inspection control posters were posted throughout the facility. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe 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 Mona Alcaraz/Administrator) .the state’s words, verbatim · CDSS document, Aug 11, 2023

Allegation investigated: Questionable death Illegal drugs on the premises Uncleared adult on the premises

On 07/07/2023, Licensing program Analyst (LPA) Mario Leon conducted an unannounced subsequent complaint visit to the facility. LPA was met by MaSheila Auingan and later by Mona Alcaraz, who were both informed that this visit was conducted to continue an investigation of the complaint allegations, previously initiated on 07/06/2023. The investigation consisted of the following: On 07/06/23, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced compaint visit at this facility.LPA toured the facility and interviewed seven (7) staff (S2-8) and two (2) witnesses (W1-2). LPA requested and reviewed three (3) LIC500 staff rosters dating back to 7/05/2022, one (1) current LIC9020 of resident roster and took photos of death reports (LIC624A) dating back to 06/2022. Report continues, see LIC9099C. Unsubstantiated On 07/07/2023 LPA conducted a subsequent visit to the facility and requested and reviewed additional facility records. LPA further interviewed the same seven (7) staff (S2-8) and interviewed three (3) out of 25 (twenty-five) residents (R2-4). On 07/06/2023 and 07/07/2023 LPA did not observe R1 or S1 present at the facility, record reviews also indicated that R1 and S1 were never present at the facility and all eleven (11) interviews corroborated that R1 and S1 were never present at the facility. The investigation revealed the following: Regarding the allegation: "Questionable death" According to the LPA's record reviews of resident identification and emergency identifications (LIC601) and Death Reports provided (LIC624A), R1 and S1 were never mentioned from 08/2022 - 07/07/23. Furthermore the LPA's interviews conducted, which were held between all seven (7) staff members, one (1) witness (W1) and three (3) residents (R2-4), there was no evidence to support the allegation listed above as all individuals previously mentioned denied knowledge of R1 or S1. In addition, S3 provided a notice stating R1 and S1 were both never present at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore the allegation is unsubstantiated. Regarding the allegation: "Illegal drugs on the premises" According to the LPA's interviews which were held between seven (7) staff members (S2-S8) and one witness (W1), all S2-S8 and W1 have denied the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore the allegation is unsubstantiated. Regarding the allegation: "Uncleared adult on the premises" According to LPA's record review of all three (3) LIC500 sheets from 07/05/2022 - 07/07/2023, S1 was not listed as present. Furthermore, S1 was not listed on the LIS facility roster summary. Furthermore all seven (7) staff (S2-S8), one (1) witness (W1) and three (3) residents (R2-4) have all denied knowledge of S1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. Therefore the allegation is unsubstantiated. An exit interview was held with MaSheila Auingan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 7, 2023 · control 11-AS-20230705090402

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) Ernand Dabuet for the purpose of delivering findings for the investigation into the above identified complaint allegations. The LPA met with Mona Alcaraz 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, and that the Licensee representative has no current liability insurance. On 12/13/2022, LPA Ernand Dabuet conducted the initial 10-day complaint investigation and conducted interviews from 9:35 a.m. to 3:08 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. (Evaluation Report continues on LIC 9099-C) Substantiated On 12/14/2022 the LPA 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. (Evaluation Report continues on LIC 9099-C) 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 LIC9099-D 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-20221212123347

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 25 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 by POC due date (05/24/23).

Allegation investigated: Resident sustained injury due to staff neglect Staff did not notify resident's authorized representatives of incident

On 5/02/2023 Licensing Program Analyst (LPA) Jeremiah Randle conducted an unannounced subsequent complaint visit at the facility listed above. LPA arrived at facility and was greeted by Administrator ALCARAZ, MONA. LPA explained the purposed of the visit is to deliver findings on the allegations listed above. The investigation consisted of the following: LPA observed facility, as well as common areas of the facility. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained throughout the facility. LPA observed the facility to be operational and in good repair., LPA requested pertinent documents pertaining to the investigation. The following documents were gathered: Staff and Client Rosters, file for resident (R1) and any other pertinent documentation needs and service, physician report, hospice records, hospital records for R1. On 03/01/2023 LPA Randle interviewed residents (R1-R6). LPA requested, received, and reviewed the following information: entire file of R1, Staff roster, Resident roster, and other documents relevant to the investigation. LPA interviewed staff (S2-S6) regarding allegations listed above. Unsubstantiated Investigation Revealed the following. Allegation: Resident sustained injury due to staff neglect Regarding Allegation #1: Resident sustained injury due to staff neglect. LPA Randle interviewed collateral witness 1(CW1) for complaint. CW1 states that R1 is in hospice care for end stage cancer. CW1 states that hospice staff had seen R1 on 02/14/2023 and there was no injury to the face of R1. CW1 states that collateral witness 2 (CW2) had called CW1 and alleged that facility staff had slapped R1 face. CW1 states that CW1 interviewed R1 who told CW1 that staff had not slapped R1 face and R1 had scratched R1 own face. CW1 states that the injury to R1 face does not look like a hand slap and more like a fingernail scratch. LPA Randle interviewed CW2-CW3 for complaint. CW2-CW3 stated that R1 told them at different times that S1 had slapped R1 face because R1 urinated in R1’s bed. CW2-CW3 stated that R1 has health issues and gets confused easily and makes up stories. LPA Randle received and reviewed color pictures of facial injury to R1 face from CW2. Reviewed color pictures of R1 face with CW1, the skin tear does not appear to come from a slap to the face with open hand and appears more in line with a fingernail scratch due to the age of R1 skin per CW1. LPA Randle interviewed CW4 for complaint. CW4 states that R1 has cognitive issues and makes up stories and gets confused. CW4 states that CW2 also makes up stories believed. LPA Randle interviewed R1 for complaint. R1 states that R1 bumped a wall in R1 room and injured R1 face cheek. R1 states that R1 then scratched R1 face opening the tear. R1 states that no staff member attacked R1 or slapped R1 face. LPA Randle interviewed R2-R6 for complaint. R2-R6 state that residents have never heard of a staff member attacking another resident and that R1 scratched R1 face, and this is how R1 injured R1 face. LPA Randle interviewed S1 for complaint. S1 states that S1 has never attacked or put S1 hands on R1 and R1 scratched R1 face then picked at scar and this is how R1 face was injured. S1 states that no resident or staff ever attacked R1. LPA Randle interviewed S2-S6 for complaint. S2-S6 state that no staff member ever put their hands or slapped R1 face and R1 scratched R1 face, and this is how R1 face was injured. S2-S6 state that they give the best service possible to all residents. LPA Randle reviewed facility file to include needs and service, physician report, hospice records, pre-placement for R1. Records suggest that R1 has cognitive impairment issues, gets confused and makes up stories. Based on information gathered, the department did not find sufficient evidence to support allegation " Staff physically abused resident in care. Allegation: Staff did not notify resident's authorized representatives of incident Regarding Allegation #2: Staff did not notify resident's authorized representatives of incident. LPA interviewed Administrator ALCARAZ, MONA (S1) denied the allegation. Administrator S1 added that R1’s has no designated POA and R1’s legal representative per R1’s physician report is her husband. S1 states that CW4 visits often usually most days. S1 states that S1 keeps CW4 informed of any issues or changes in condition. LPA interviewed CW4, CW4 stated that S1 keeps him informed of resident R1 condition and that he loved the facility, and the facility cares for R1’s needs. LPA interviewed residents (R2-R7) regarding the allegation Staff did not notify resident's authorized representatives of incidents. Residents interviewed all stated (R2-R7) they had no problem with staff communicating their change of condition or incidents to their authorized representatives. LPA interviewed staff (S2-S6) regarding allegation all stated there were no delays in communicating to authorized representatives of changes to residents’ condition or incidents. Based on information gathered, the department did not find sufficient evidence to support allegation Staff did not notify resident's authorized representatives of incident The Department’s investigation consisted of an inspection of the facility, observation, analysis of facility records and interviews conducted and found No evidence to support the allegations: Resident sustained injury due to staff neglect Staff did not notify resident's authorized representatives of incidentAlthough 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. An exit interview was conducted with Administrator ALCARAZ, MONA and a hard copy was provided.the state’s words, verbatim · CDSS document, May 2, 2023 · control 11-AS-20230222081854

Allegation investigated: Staff physically abused resident in care.

This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 03/01/2023. Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to the facility Bentley Manor on 03/01/2023 and was greeted by Administrator Mona Alcaraz (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations. During this investigation, LPA Calderon interviewed A1, W2-W4, S2-S6, R1-R10. These interviews were conducted on 02/27/2023 and 03/01/2023. On 03/01/2023 LPA Calderon requested copies of the following: Staff LIC500 and Resident rosters, needs and service, physician report, hospice records, hospital records, incident report for R1. Unsubstantiated Regarding Allegation #1: Staff physically abused resident in care. The investigation revealed the following: Regarding Allegation #1: Staff physically abused resident in care. On 03/01/2023 LPA Calderon interviewed R1 for complaint. R1 states that R1 “bumped a wall” in R1’s room. R1 states this caused the injury to R1’s face. R1 then scratched R1’s face and this created a tear in the skin. R1 states the injury was not the result of staff physically abusing R1. On 03/01/2023 LPA Calderon interviewed R2-R6 for this complaint and 5 out of 5 residents affirmed they have not heard or witnessed facility staff physically abuse residents. On 03/01/2023 LPA Calderon interviewed A1 who reports R1 scratched R1’s face and this caused an open wound on R1’s face. A1 stated R1 re-injured the scratch when touching the area after it developed a scab. On 03/01/2023 LPA Calderon interviewed S2-S7 for complaint and 6 out of 6 staff members expressed they have not witnessed facility employees physically abuse residents and the cause of R1’s wound was the result of R1 scratching R1’a face. Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff physically abused resident in care” is found to be UNSUBSTANTIATED. An exit interview was conducted and copy of the Complaint Report was provided to the Administrator Mona Alcaraz (A1).the state’s words, verbatim · CDSS document, Mar 1, 2023 · control 11-AS-20230224093036

Type of visit: Post Licensing

On 12/13/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced post licensing visit using the CARE Inspection Tool. LPA met with assistant administrator Sheila Auingan and explained the purpose of today’s visit. The facility is licensed to operate for (27) elderly non-ambulatory adults of which (5) may be bedridden. The facility is approved for (8) hospice residents. Currently, there are (3) hospice residents. The facility is a two-story structure located in a residential neighborhood. It consists of the following: (17) resident's rooms with a bathroom in each room, a living area, a dining area, a kitchen, and an outside patio area. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature was tested for rooms: #5 112.9 F; #4 114.6 F; #3 109.6 F; #2 105.0 F; #11 115.0 F, and #17 117.6 F A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has several fire extinguishers that were charged, smoke detectors, and carbon monoxide was operable. The facility conducted a Fire/Safety Drill on 11/01/22. A working landline telephone remains available. The facility maintains a PRN Medication Log. Evaluation Report Continues on LIC 809-C DEFICIENCIES: Based on record reviews, LPA identified staff #2 through #10 (S2-S10) did not have a Criminal Clearance Background Clearance Transfer for all (9) employees and were not associated at this facility. The administrator is being cited according to Administrator's Qualifications Regulations 87405 resulting in multiple deficiencies cited. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. IMMEDIATE CIVIL PENALTY Deficiency are issued and an exit interview is conducted with Sheila Auingan. A copy of this report, appeal rights, and civil penalty were provided.the state’s words, verbatim · CDSS document, Dec 13, 2022

Type of visit: Case Management - Other

On 8/11/2022 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 7/22/2022. LPA observed the following on 8/11/2022 -No pests were found in facility kitchen. 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, Aug 11, 2022

Type of visit: Case Management - Other

On 8/3/2022 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 7/22/2022. LPA observed the following on 8/3/2022 -LPA observed live pests in the kitchen at 1:30pm Pre-licensing cannot be completed until this deficiency is cleared. LPA is giving a POC due date of 8/17/2022. Exit interview conducted with Administrator Ma Sheila Auingan and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 3, 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 7/22/2022. LPA observed the following on 7/26/2022 -A bed was placed in room 17, facility now has 27 bed, which is requested capacity. -Water temperature in 14 of the bathrooms is under 105F -No locks on kitchen cabinets or drawers for sharps or toxins, toxins found in cabinet and knives in drawer. Done -several rooms are in need of repairs such as new screens in windows, small holes in bathroom wall, overhead lights not working. LPA went through rooms and saw that repairs had been made. -Extra dressers were added to Room 3 to create additional storage. -Pests were not found in two residents rooms. The following still needs to be completed: -On 7/26/2022 and 7/22/2022 pests were found in kitchen. 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 7/22/2022 Licensing Program Analysts (LPA’s), Stephanie Cifuentes and Perry Scott 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 27 clients,22 non-ambulatory, 5 bedridden. Facility has a dementia care plan in place. LPA was greeted and accompanied on inspection by Licensee/administrator Mona Alcaraz Structure: Facility has 19 resident bedrooms, 17 client bathrooms, 2 living room/ lounge areas, 2 dining rooms and kitchen. Facility is two stories. The client bedrooms are spacious and will easily accommodate the client's furnishings. There is a shaded front 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. Bedrooms Residents: LPA observed 19 resident bedrooms, 5 bedrooms are for bedridden and 14 bedrooms are for non-ambulatory. Bedrooms 3a/b, 3c/d and 11a/b, 11c/d have two beds, two chairs, nightstands, overhead lighting, closet and two dressers with several drawers. Bedrooms 1, 2, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, have one bed, one chair, one-night stand, overhead lighting, closet or wardrobe and a dresser with several drawers. overrhead lighting, and dressers with several drawers. Most drawers comply with the requirement of 8 cubic feet of space and there was ample closet space. Bathroom: Facility has 15 client bathrooms and 2 half baths. Bathrooms1-16 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. Continued on 809-C 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 a first floor cupboard.. 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. Three fully charged fire extinguisher were found, one in kitchen and one in downstairs hallway and one in upstairs hallway. Toxins: Toxins locked/stored in hall cupboard and under kitchen sink. Water temperature: Water temperature in kitchen and bathrooms measured between 98.3F to 112.5F. 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: Twenty-four (24) smoke detectors are hardwired and interconnected. 2 carbon monoxide detectors were fond, one on each floor. 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 at staff desk. Continued on 809-C Reading Material, Games, Equipment & Materials: The facility has an activity calendar and provides puzzles other games and papercrafts as well as ball toss and Tai Chi. Doors have auditory devices to monitor exits. Pool/Jacuzzi & Pets: LPA's did not observe any pets or bodies of water at the facility. Fire clearance: Fire Clearance was approved on 6/17/2022 for 5 bedridden client and 22 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: -Only 26 beds were found and requested capacity is 27. -Water temperature in 14 of the bathrooms is under 105F -No locks on kitchen cabinets or drawers for sharps or toxins, toxins found in cabinet and knives in drawer. -several rooms are in need of repairs such as new screens in windows, small holes in bathroom wall, overhead lights not working. -Room 3 has insufficient storage space. -Pests where found in kitchen and two of the residents rooms -Outside activity area is not properly enclosed with self-closing latches 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 Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.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: 27 Census (if any clients in care): 23 Method: Telephone at CAB COMP II Participants: Mona Alcaraz (Applicant) and Robin Aquino (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