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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 11/19/2021
Date Signed: 11/19/2021 03:03:08 PM

Document Has Been Signed on 11/19/2021 03:03 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENTITS RETIREMENT VILLAFACILITY NUMBER:
198603173
ADMINISTRATOR:MARALIT, TERESITAFACILITY TYPE:
740
ADDRESS:1301 N BIRCHNELL AVETELEPHONE:
(626) 335-9598
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 4DATE:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tita Bartolata, caregiverTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Tita Bartolata and explained the reason for the visit. Caregiver called Administrator, Tita Bartolata, but Administrator never called back. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been approved.

All resident bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 108.9 degrees which is within the required 105 - 120 degrees. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. The common areas including the living rooms and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. The facility has cameras in the hallway and common areas only.

LPA reviewed all resident files. Resident #1 (R1) is missing an admission agreement, pre-admission appraisal, and proof of TB test. Resident #2's (R2) admission agreement is from 2016 and lists the name of the previous owner of the facility and was never updated for the new owner. LPA reviewed staff files. Staff #1 (S1) did not have a personnel file in the facility. According to Staff #2 (S2), S1 is only a reliever and does not have a personnel file. S1's name is also not associated to the facility and without a file at the facility, does not have proof of fingerprint clearance. LPA reviewed 4 residents' medications. Medications are documented properly and given as prescribed. At the time that LPA entered the facility staff did not assess or take LPA's temperature. Also 2 visitors were seen entering the facility and staff did not assess those individuals and did not have them sign in as required for COVID-19 procedures.
Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached 809D. Exit interview held. A copy of the report and appeal rights were provided to caregivers.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/19/2021 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/19/2021 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 2 staff members which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2021
Plan of Correction
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Administrator will not allow S1 to work without proof of fingerprint clearance. Administrator will certify that all staff working will have fingerprint clearances and will certify that S1 will not continue to work until a criminal record clearance is obtained. Certification is due by 11/20/21. This will result in a civil penalty.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/19/2021 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/19/2021 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Per COVID-19 procedures and facility Mitigation Plan, staff are required to conduct routine symptom screening (+/- temperature and symptom check) for all staff, residents, and visitors. LPA was not screened during the visit. Also 2 visitors were observed entering the facility and they were also not screened.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will submit proof of training for all staff regarding screening of all visitors. Proof of training will be submitted by 12/3/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/19/2021 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/19/2021 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Facility is required to have a sign-in policy per COVID-19 procedures and as indicated in the approved Mitigation Plan. LPA was not asked or required to sign-in at the time of entry. Also 2 visitors were observed entering the facility and they were also not asked to sign-in.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will submit proof that staff have been trained on sign-in procedures. Proof of training will be submitted by 12/3/21.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/19/2021 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/19/2021 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interviews conducted, the licensee did not comply with the section cited above in 1 out of 2 staff members which poses a potential health, safety or personal rights risk to persons in care. Staff #1 (S1) did not have a personnel file at the facility. According to Staff #2 (S2) S1 is only a reliver and does not have a personnel file.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will submit S1's personnel file to the department for review. Administrator will provide the file by 12/3/21.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 4 resident files which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) did not have a pre-admission appraisal on file.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will complete a pre-admission appraisal for R1. Appraisal will be submitted by 12/3/21 for review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/19/2021 03:03 PM - It Cannot Be Edited


Created By: Tony Vasallo On 11/19/2021 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records reviewed, the licensee did not comply with the section cited above in 1 out of 4 resident records which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) did not have proof of TB test on file.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will obtain proof of TB clearance for R1. TB test results will be submitted to the department for review by 12/3/21.
Type B
Section Cited
CCR
87507(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 4 resident files which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) did not have an admission agreement on file. Resident #2 (R2) had the wrong admission agreement on file. R2's agreement lists the previous owner's facility name. This agreement must be corrected to list the new owner's information.
POC Due Date: 12/03/2021
Plan of Correction
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Administrator will submit complete admission agreements for both residents. Admission agreements will be submitted by 12/3/21 for review.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Wei Siew Ho
LICENSING EVALUATOR NAME:Tony Vasallo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2021


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