Bentley Manor

Allegation investigated: Staff are not adequately addressing the catheter needs of the residents. Staff are not addressing the resident's change in condition with an proper wound care plan.

On 02/17/2026, at 11:35 AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met with Mona Alcaraz-Administrator who was informed of the purpose of the visit. The investigation consisted of the following: On 2/17/2026 at 11:45 AM LPA Allen conducted and review of resident 1(R1) file that included the Identification and Emergency information dated 2/3/2026, LIC602 medical assessment dated 1/30/2026, admissions agreement, Pre-placement dated 2/3/2026, levels of care assessment tool dated 1/28/2026, AAA Hospice Care Nursing Inc. plan of care dated 2/10/2026 along with Bentley Manor and AAA Hospice Care & Nursing Inc. sign in sheets from January 31,2026 through February 17, 2026 and the staff and resident roster. LPA also conducted interviews with Residents 1-5 (R1-R5) and Staff Members 1-5 (S1-S5). Continued Unsubstantiated The investigation revealed the following: #1- Allegation: Staff are not adequately addressing the catheter needs of the residents. Interviews with Residents (R1–R5) were asked whether staff address their catheter needs and 1 out of 5 residents, stated that their catheter needs are being met by staff, who check on them every two hours or as needed. R1 informed (LPA) that staff are not permitted to assist with catheter care, but they do ensure that incontinence needs are met daily. R1 also reported that a hospice nurse visits the facility at least once a week to assist with catheter care. The remaining four residents (R2–R5) stated that they do not require catheter care. Interviews with Staff members (S1–S5) were asked if staff are addressing the catheter needs of the residents and 5 out of 5 staff members confirmed that catheter care is provided only by a licensed professional. Staff are permitted to empty residents’ urinal bags but not perform catheter care. Staff also reported that AAA Hospice Care & Nursing Inc. is the agency providing catheter care to residents once a week, with additional visits pending approval. #2 Allegation: Staff are not addressing the residents’ change in condition with an proper wound care plan. Interviews with Residents (R1–R5) were asked if staff are addressing changes in residents’ condition with a proper wound care plan and 1 out of 5 residents stated staff have been addressing their wound care needs by notifying the hospice agency /medical professional and visits are conducted once a week by a hospice agency. The remaining four residents (R2–R5) stated that they do not require wound care. Interviews with Staff (S1–S5) were asked if staff are addressing the residents change in condition with proper wound care plan and 5 out of 5 staff members stated that residents requiring wound care would receive services from a hospice agency/or medical professional. Staff also reported that they are not permitted to provide wound care, but they may perform bandage changes as needed. Based on staff observations, if additional care is required, the hospice agency is contacted immediately for further action. LPA reviewed the guest sign in sheet from 1/31/2026 through 2/17/2026 that reflects visits were made from the hospice nurses along with AAA Hospice Care & Nursing Inc. Flow Sheet dated for services rendered on 2/10/2026, 2/17/2026 for additional care and route sheets dated for 2/6, 2/7,2/10.2/12 and 2/14, 2026. Based on interviews, documents reviewed and observation during the investigation, the above allegation is found to be Unsubstantiated; meaning that 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. An exit interview was conducted where this report was discussed and provided to Mona Alcaraz Administrator at conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 11-AS-20260209231108

Allegation investigated: Staff did not provide resident medication as prescribed. Staff restrained resident in a chair.

**This report does not supersede the previous report dated 11/21/25 but is used to clarify findings. ** On 02/11/2026 at approximately 09:40 AM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the above, listed facility to deliver findings. The LPA was greeted by the Administrator Mona Alcaraz and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: On 08/01/2025 between 04:36 PM – 05:00 PM, the department requested, reviewed, and obtained copies of the Staff Roster, Client Roster, and Physician’s Reports. On 09/25/2025 between 10:09 AM – 04:48 PM, the department requested and obtained the Centrally Stored Medication Destruction Records (CSMDR). CONTINUED ON LIC9099-C Unsubstantiated On 11/21/2025, the department obtained an Unusual Incident Report dated 07/16/2025. On 09/25/2025, the department conducted interviews with Staff #1 – #5 (S1–S5) and Residents #2 – #4 (R2–R4). An attempt to interview Resident #1 (R1) was made, but R1 was unavailable because they had passed away prior to the initial visit. LPA toured the facility with Administrator Mona Alcaraz and found the facility to be clean and in good repair. The investigation revealed the following: Allegation: Staff did not provide resident medication as prescribed It was alleged that staff did not provide resident medication as prescribed. On 09/25/2025 between 10:09 AM – 04:48 PM, the department conducted interviews with Residents #2 – #4 (R2–R4). An attempt to interview Resident #1 (R1) was made, but R1 was not present because R1 moved out of the facility on 07/20/2025 prior to the visit. The department asked the residents if staff provided them with their medication as prescribed by their physician. Of those interviewed, 3 out of 3 residents denied the allegation. On 11/21/2025 at approximately 03:20 PM, the department conducted an interview with the Administrator (A1). A1 was asked if staff provided residents with medication as prescribed. A1 stated, “We don’t give any medication without a prescription; it must be prescribed by their doctors.” On 09/25/2025 between 10:09 AM – 04:48 PM, the department conducted interviews with Staff #1 – #5 (S1–S5). The department asked staff if they assisted residents with their medication as prescribed by their physician. Of those interviewed, 5 out of 5 staff denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, the department obtained and reviewed the Centrally Stored Medication Destruction Records (CSMDR), which showed that all residents interviewed received their medication as prescribed by their physicians. The department requested Medication Administration Records (MAR), but the Administrator informed the department that the facility only documents medication administered to residents via the CSMDR. A thorough review of the CSMDR showed that the dates and times of distribution for each resident were current at the time of the visit. Based on the information gathered, interviews conducted, and review of records, the department found no 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 UNSUBSTANTIATED. CONTINUED ON LIC9099-C Allegation: Staff restrained a resident in a chair It was alleged that staff restrained a resident in a chair using a band of some sort to keep the resident from falling out of the chair. On 09/25/2025 between 10:09 AM – 04:48 PM, LPA Watson conducted interviews with Residents #2 – #4 (R2–R4). Per Administrator Mona Alcaraz, the facility was informed on 07/20/2025 that R1 would not be returning. On 11/21/2025 at approximately 03:20 PM, LPA Watson conducted an interview with the Administrator Mona Alcaraz (A1). A1 was asked about the allegation regarding staff restraining a resident in a chair. A1 stated that this practice does not occur in the facility and staff have not received in-service training in restraining residents. On 09/25/2025 LPA Watson interviewed Resident#2-Resident#4 (R2-R4) and asked them if staff ever restrained them or another resident in a chair using a band of some sort to keep them from falling out of the chair. Of those interviewed, 3 out of 3 residents denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, the department conducted interviews with Staff #1 – #5 (S1–S5). The department asked staff if they restrained a resident in a chair at the facility. Of those interviewed, 5 out of 5 staff denied the allegation. On 09/25/2025 between 10:09 AM – 04:48 PM, LPA Watson obtained and reviewed R1’s Physician’s Report, which showed that no resident residing in the facility is required to be restrained. The department toured the facility with Administrator Mona Alcaraz and found no evidence of restraining devices that could have been used as restraints to secure residents in chairs. Based on the information gathered, interviews conducted, and review of records, the department found no 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 UNSUBSTANTIATED. No deficiencies were cited. An exit interview was conducted with Administrator Mona Alcaraz, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 11, 2026 · control 11-AS-20250722134621

Allegation investigated: Staff did not provide resident medication as prescribed. Staff restrained resident in a chair.

**This report serves as an amendment to clarify findings and does not supersede the complaint investigation findings reflected on the report created 09/25/25** On 11/21/2025 at approximately 01:30 PM Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced visit to the above-listed facility to deliver findings. The department was greeted by the Administrator and explained the purpose of the visit. LPA was granted entry into the facility. The investigation consisted of the following: CONTINUED ON LIC9099-C Unsubstantiated On 08/01/2025 between 04:36 PM - 5:00PM the department requested, reviewed, and obtained copies of the Staff Roster, Client Roster, Physicians Report. On 09/25/2025 between 10:09 AM – 04:48 PM the department requested and obtained the foll(owing: Centrally Stored Medication Destruction Record (CSMDR). On 11/21/2025 the department obtained an Unusual Incident Report dated 07/16/2025. On 09/25/2025 (10:09 AM – 04:48 PM) the department conducted interviews with Staff #1 - #5 (S1-S5) and Resident #2-#4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 moved out of the facility on 07/20/2025 prior to the visit. LPA toured the facility with Administrator Mona Alcaraz. The investigation revealed the following: Allegation: Staff did not provide resident medication as prescribed It is being alleged that staff are over-medicating residents and not providing medication as prescribed. Three out of three residents (R2 – R4) indicated staff provided them with their medication as prescribed by their physician. On 11/21/2025 at approximately 03:20 PM the department conducted an interview with the Administrator (A1). A1 was asked if staff provided residents with medication as prescribed, and A1 said we don’t give any medication without prescription if it is not prescribed by their doctors. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Staff #1- #5 (S1-S5). Five out of five staff interviews indicated (S1-S5) they assisted residents with their medication as prescribed by their physician. On 09/25/2025 between 10:09 AM – 04:48 PM the department obtained and reviewed the Centrally Stored Medication Destruction Record (CSDMR’s) and it showed that all residents interviewed received their medication as prescribed by their physicians. The department requested Medication Administration Records (MAR’s) from the facility but was informed by the administrator that they only documented medicine administered to residents via the Centrally Stored Medication Destruction Record (CSMDR’s). A thorough review of the CSMDR’s showed that all medicines including R1 were current at the time of visit. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation mentioned above. 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 Unsubstantiated. CONTINUED ON LIC9099-C Allegation: Staff restrained a resident in a chair. It is being alleged that staff restrained Resident #1 (R1) in a chair using a band to keep the resident from falling out of a chair. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Residents #2- #4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 was not present at the time of visit. The department obtained and reviewed an SIR report that showed R1 was transferred to An interview with the Administrator (A1) revealed that R1’s Responsible Party later called the facility on 07/20/2025 and said that R1 was not returning back to the facility. On 11/21/2025 at approximately 03:20 PM the department conducted an interview with the Administrator (A1). A1 was asked about the above allegation, did staff restrain a resident in a chair. A1 stated that it is not practiced in the facility, nor has A1’s staff received in service training in restricting patients. The department asked the residents if staff ever restrained them or another resident at the facility in a chair using a band of some sort to keep them from falling out of the chair. Of those interviewed, 3 out of 3 residents (R2-R4) denied the above allegation. On 09/25/2025 between 10:09 AM – 04:48 PM the department conducted interviews with Staff #1- Staff #5 (S1-S5). On 09/25/2025 the department asked the staff if they restrained a resident in a chair at the facility. Of those interviewed, 5 out of 5 staff denied the above allegation. The department toured the facility with the Administrator Mona Alcaraz and found no evidence of devices that could have been used as restraints. Based on the information gathered, interviews conducted, and review of records, the department found no evidence to support the allegation mentioned above. 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 Unsubstantiated. No deficiencies were cited. An exit interview was conducted with the Administrator Mona Alcaraz and a copy of this report was given.the state’s words, verbatim · CDSS document, Nov 21, 2025 · control 11-AS-20250722134621

Allegation investigated: Staff did not provide resident medication as prescribed. Staff restrained resident in a chair.

On 09/25/2025 Licensing Program Analyst (LPA) Troy Watson made a subsequent unannounced complaint visit to the above-listed facility. LPA Watson was greeted by the Administrator Mona Alcaraz and explained the purpose of this visit is to investigate the allegations listed above. LPA was granted entry into the facility. The investigation consisted of the following: On 08/01/2025 Licensing Program Analyst (LPA) Watson requested, reviewed, and obtained copies of the Staff Roster, Client Roster, and Physician Report. On 09/25/2025 LPA Watson requested and obtained the following: Centrally Stored Medication Record (CSMDR). On 09/25/2025 LPA conducted interviews with Staff #1 - Staff #5 (S1-S5) and Resident #2- Resident #4 (R2-R4) An attempt to interview Resident #1 was made but they were not present at time of visit. LPA toured the facility with Administrator Mona Alcaraz. LPA found the facility to be clean and in good repair. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not provide resident medication as prescribed On 09/25/2025 LPA Watson conducted interviews with Residents #2- Residents #4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff provided them with their medication as prescribed by their physician. Of those interviewed, 4 out of 4 residents denied the above allegation.On 09/25/2025 LPA Watson interviewed Staff #1- Staff #5 (S1-S5). LPA Watson asked the staff if they assisted residents with their medication as prescribed by their physician. Of those interviewed,5 out of 5 staff denied the above allegation. On 09/25/2025 LPA Watson reviewed the (CSDMR’s) and it showed that all residents interviewed received their medication as prescribed by their physicians. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. 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 Unsubstantiated. Allegation: Staff restrained a resident in a chair. On 09/25/2025 LPA Watson conducted interviews with Residents #2- Residents #4 (R2-R4). An attempt to interview Resident #1 (R1) was made but R1 was not at the facility at the time of the interviews. LPA Watson asked the residents if staff ever restrained them or a resident in a chair. Of those interviewed, 4 out of 4 residents denied the above allegation.On 09/25/2025 LPA Watson interviewed Staff #1- Staff #5 (S1-S5). LPA Watson asked the staff if they restrained residents in a chair at the facility. Of those interviewed, 5 out of 5 staff denied the above allegation. On 09/25/2025 LPA Watson reviewed Physicians Reports, and it showed that no resident residing in the facility needed to be restrained. Based on the information gathered, interviews conducted, and review of records LPA Watson found no evidence to support the allegation mentioned above. 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 Unsubstantiated. An exit interview was conducted with the Administrator Mona Alcaraz and a copy of this report was given.the state’s words, verbatim · CDSS document, Sep 25, 2025 · control 11-AS-20250722134621

Type of visit: Required - 1 Year

On 09/18/25 at 10:00am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced annual required visit to Bentley Manor. LPA met with Mona Alcaraz, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve (27) non-ambulatory elderly adults aged 60 and above, of which (5) may be bedridden. The facility has an approved hospice waiver for (8) in rooms: 3A, 3B, 3B, 3C, 3D, 4A, 4B, 5, and 6, which are cleared for bedridden residents. Currently, the facility has (24) residents. The facilities annual fees are current. The facility is a two-story building located in a residential neighborhood. It consists of the following: seventeen (17) bedrooms with a bathroom in each room, a living area, a dining area, a kitchen, and an outside shaded patio area with tables, chairs, and umbrellas. LPA conducted a records review of (10) resident records, (6) staff records, and reviewed the facility disaster plan. All resident and staff records were complete. All staff were associated with the facility and had a criminal record clearance or exemption. The facility disaster plan was current and in compliance with Title 22 regulations at the time of visit. LPA reviewed (10) resident Centrally Stored Medication and Destruction Records, and medication, and did not observe any discrepancies at the time of visit. At 10:30am, LPA and staff toured the facility. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, and adequate storage for resident’s personal belongings was observed. Walls and floors were in good repair. Report Continued on LIC809-C Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries are accessible to clients. The water temperature ranged from 111.4F° – 117.3F° degrees throughout the facility. A comfortable temperature was maintained throughout the facility. LPA observed the facility to be clean, sanitary, and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to residents. The kitchen was inspected and there is enough perishable and non-perishable food available for the residents. All food items were stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked with manual. The fire extinguishers were charged and last serviced on 01/23/2025. The smoke and carbon monoxide detectors were operable. The last fire/emergency drill was conducted on 07/14/2025. The facilities administrator’s certificate was valid from 06/05/2024-06/04/2026. The facilities liability insurance was valid from 08/26/2025 through 08/26/2026. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA advised the facility to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. No deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this Facility Evaluation Report was provided to Mona Alcaraz, Administrator.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Troy Watson conducted an unannounced visit to Bentley Manor on 08/19/2024 at 09:15 AM. The LPA met with the Administrator Mona Alcaraz, and the purpose of the visit was explained. Facility is licensed to serve 27 non- ambulatory residents and currently has a census of (24) of which 3 are bed-ridden and the facility has an approved hospice waiver for eight residents. Some residents are diagnosed with dementia and some residents are receiving hospice care services. The facility does not handle any of the resident’s money. Because of time restraints the inspection could not be completed at this timethe state’s words, verbatim · CDSS document, Aug 19, 2024

Allegation investigated: Staff do not ensure that resident's incontinence needs are met. Staff do not maintain facility clean and sanitary at all times. Staff are not addressing rodent problem.

On 08/09/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Mona Alcaraz and explained the purpose of the visit. The investigation consisted of the following: During today’s investigation, LPA toured the facility, observed mealtime, and interviewed 10 residents and four (4) staff members which included the Administrator, Cook/Caregiver, and two (2) Caregivers. On 09/07/23, Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced complaint visit on and met with Assistant Administator Mashelia Aungan. LPA Bunker explained the purpose of today's visit. The investigation consisted of the following: Interviews conducted. LPA Bunker asked questions relevant to the nature of the complaint. Ms. Mashelia and LPA Bunker toured the buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. We did not observe any signs of neglect or abuse during today's visit. LPA Bunker requested and reviewed resident 1's (R1) records and requested copies of supporting documents. Due to insufficient information available at this time, the above allegations need further investigation. There were no Allegation(s): Staff do not ensure that resident's incontinence needs are met. The investigation revealed the following: Regarding the allegation "Staff do not ensure that resident's incontinence needs are met,” it is being alleged that Resident #1’s (R1) underwear is left soiled in feces and urine. In addition R1 has two open wounds on R1’s backside and one is a result of staff not changing R1. On 08/09/24, LPA Cloyd observed that the facility remained free of odors from incontinence. Three (3) out three (3) residents indicated that staff regularly assist them with incontinence needs and there are no complaints. Seven (7) out of seven (7) staff members, including the Administrator, indicated that residents are changed 2-3 times during the day and whenever residents have an emergency. The Administrator indicated R1 followed the same incontinence schedule and that staff made sure that R1 was changed before third-party agencies arrived. Regarding the allegation, “Staff do not ensure that resident's incontinence needs are met,” based on the interviews and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation(s): Staff do not maintain facility clean and sanitary at all times. The investigation revealed the following: Regarding the allegations "Staff do not maintain facility clean and sanitary at all times,” it is being alleged that food trays are left on the counters attracting rats. On 08/09/24, LPA Cloyd did not observe trays, but tableware placed on carts to transport food to the first and second floor dining table. Plates were either walked to the kitchen by staff or placed on the cart until everyone finished their lunch. LPA observed a resident eating in his room and the tableware was removed upon completion. Six (6) out six (6) residents indicated that plates are removed from the eating area quickly. Seven (7) out of seven (7) staff members, including the Cook, indicated that plates are removed quickly, the common areas and resident rooms are cleaned daily, and they have not seen rats. The Administrator indicated that staff sweep at night because some residents like to eat and drop crumbs. LPA observed the facility to be clean and sanitary. Continue to LIC9099-C. Regarding the allegation, “Staff do not maintain facility clean and sanitary at all times,” based on the interviews and observations, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation(s): Staff are not addressing rodent problem. The investigation revealed the following: Regarding the allegations, “Staff are not addressing rodent problem,” it is being alleged that rats enter the facility and leave droppings. On 08/09/24, LPA Cloyd did not observe rat droppings in resident #1’s (R1) former bathroom nor in the facility. Eight (8) out of nine (9) resident interviews indicated that they have not seen rats in the facility. All staff interviews indicated that the facility does not have a rodent problem. Record review reveals that the facility receives monthly pest control as of 2006. Interview with the Administrator indicated that a special pest control service was added once she learned about the rat allegation in September 2023. Regarding the allegation, “Staff are not addressing rodent problem,” based on the interviews, observations, and record reviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies were cited for these allegation(s). An exit interview was conducted and a copy of this report was provided to the Administrator Mona Alcaraz.the state’s words, verbatim · CDSS document, Aug 9, 2024 · control 11-AS-20230828142032