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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 11/24/2021
Date Signed: 11/24/2021 02:01:00 PM

Document Has Been Signed on 11/24/2021 02:01 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:
11/24/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Tita Bartolata, CaregiverTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Vasallo conducted a Plan of Correction (POC) visit. LPA met with caregiver, Tita Bartolata and explained the reason for the visit. Caregiver contacted Administrator, Teresita Maralit and Administrator was interviewed over the phone.

The purpose of the visit was to follow-up on deficiencies cited during an annual visit on 11/19/21. During the annual visit, facility was cited for Staff #1 (S1) not having proof of fingerprint clearance. The POC was due by 11/20/21 and LPA never received the POC. Administrator was interviewed over the phone today and she indicated she was still working on the fingerprint clearance and therefore has not submitted a POC.

Civil penalties will be assessed for not submitting the POC prior to the due date. Exit interview held with caregiver. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Tony Vasallo
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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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