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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320302
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:54:23 PM

Document Has Been Signed on 08/03/2022 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:BENTLEY SUITESFACILITY NUMBER:
198320302
ADMINISTRATOR:AQUINO, ROBINFACILITY TYPE:
740
ADDRESS:851 4TH STREETTELEPHONE:
(213) 478-0460
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY: 44CENSUS: 27DATE:
08/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:51 PM
MET WITH:Mona AlcarazTIME COMPLETED:
04:30 PM
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On 8/2/2022 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 8/2/2022
1. Facility layout matches newly provided floor plan provided which has also been submitted to CAB.
2. Bedrooms 3, 18, 15 and 10 have sufficient number of beds.
3. Bedrooms 12, 17, 18, 19, and 21 have working lights.

The following still needs to be completed:
- Bathrooms water temperatures measure under 105F.

POC due date is 8/17/2022.

Exit interview conducted with staff Divine Diaz and a copy of this report was provided
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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