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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:55:51 PM

Document Has Been Signed on 11/18/2022 03:55 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:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tita Bartolata- CaregiverTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado conducted an annual required visit. LPA met with caregiver Jonathan Diel and explained the purpose for the visit. Caregiver Tita Bartolata called Administrator Teresita Maralit to notify her of the visit. LPA used the Infection Control Tool to evaluate the facility. LPA inspected the physical plant with caregiver Tita, reviewed COVID-19 procedures, residents' medications, resident and staff files, and observed the food supply. Facility has submitted a mitigation plan and the plan was approved.

The facility consists of (5) bedrooms, of which (1) is for live-in staff, (3) bathrooms of which (1) is for live-in staff, a living room, kitchen, dining room, TV room, shaded patio in the backyard and a detached garage. All resident bedrooms were toured and observed to have a smoke detector, the required furniture, linens, and sufficient closet and storage space. All bathrooms were observed to have a toilet, shower, and wash basin. The staff bathroom has a Jack & Jill hand wash sink and the sink to the right side was observed to be broken and inoperable with a bag covering it. Staff stated her boss is aware of it. The resident bathrooms were observed to have the required non-skid mats and grab bars. The hot water was tested and measured at 116*F in the staff bathroom and 131.5*F in the resident bathroom. The second resident bathroom did not have any running hot water at the hand wash sink. The staff stated her boss turned off the hot water to keep residents from burning themselves. The hot water requirement is currently not being met. The kitchen was toured and all appliances were operating properly. There was a sufficient amount of perishable and non-perishable food in the kitchen refrigerator, the kitchen pantry, and the refrigerator in the garage. LPA observed the vent in the dining area to be full of dust. The cabinets underneath the kitchen sink are broken and appears to be leaking. A tub of water was observed under the sink with some pads laid on the floor to absorb the water. All sharps were observed to be stored in a drawer next to the kitchen sink, however the lock on the drawer is broken, making the sharps easily accessible. LPA observed a cabinet near the entrance of the laundry room to the right, that stored cleaning supplies/toxins and laundry supplies

(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VILLA
FACILITY NUMBER: 198603173
VISIT DATE: 11/18/2022
NARRATIVE
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    The cabinet did not have a lock and was accessible. Staff stated there should be a lock there, but the lock hinge is bent and does not close properly. The First Aid Kit was inspected and LPA discovered it was missing scissors, a thermometer, and bandages/roll bandages. A First Aid Manual was also missing. Staff stated she was unaware a manual was required- has never been asked for one before. The garage is used for storage and parking. LPA observed several cameras in the facility, located in the hallway and common areas only. The smoke/carbon monoxide detectors were tested and observed to be operational. Several fire extinguishers were observed throughout the facility with recent inspections and were fully charged.

LPA reviewed all 4 resident files. Resident #1 (R1) is only has an admissions agreement on file and missing all other required documents. R2 and R4 are dementia care residents and do not have an updated medical assessment and reappraisal as required annually, for persons with dementia. During staff file review, it was discovered that caregiver Jonathan did not have a personnel file in the facility to review, but staff has fingerprint clearance and was associated to the facility. Caregiver Tita did not have current CPR/First Aid certification (exp 06/201), and did not have proof of required annual training certification on file. 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 until LPA asked them to. When caregiver Jonathan opened the door to greet LPA, caregiver was observed to not be wearing a face mask, as required for COVID-19 procedures. Caregiver Tita was wearing a face mask, however it was hanging below her chin- not used properly. LPA asked both staff to place masks on properly and maintain them on during work hours, as required by COVID-19 procedures.Visitors were also observed to come in the facility without being properly screened and were not wearing face masks as required. LPA observed a 30-day supplies of Personal Protective Equipment (PPE) available and the required COVID-19 signgage posted throughout the facility to promote hand washing, cough/sneeze etiquette, and social distancing. LPA observed cloth hand towels at all hand wash stations and advised staff to remove them, as only paper towels should be used, per COVID-19 procedures.

Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached LIC809-D. Technical Advisories were also issued regarding COVID-19 practices.

An exit interview was conducted and a copy of the report, technical advisories, and appeal rights were provided to caregivers.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 11/18/2022 03:55 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/18/2022 at 03:25 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: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in the water temperature measuring at 131.5*F in bathroom# 1 and no hot water running in bathroom# 2, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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Licensee will turn on the hot water in bathroom# 2 and adjust the water temperature to measure within the required limits of 105*F-120*F by the POC due date. A temperature log will need to be completed for the following 7 days and submitted to LPA via email by 11/25/22.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in cleaning supplies and toxins were stored in the laundry room, unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
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Licensee will remove all cleaning supplies and toxins from the closet and place them somewhere inaccessible to residents in care, or a lock will be placed and kept on the cabinet at all times. Licensee will send LPA a picture of the properly stored items via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/18/2022 03:55 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/18/2022 at 03:25 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: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in the cabint underneath the kitchen sink was broken and leaking, the vent in the dining room has accumulated dust, and there is not running hot water in bathroom# 2, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will have cabinet under the kitchen sink fixed and plumbing fixed to stop the leak, and will turn on the hot water tap in bathroom# 2. Licensee will send a picture of the corrections and of the recipts for the work completed to LPA via email by the POC due date.
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 of 2 staff files were not available to inspect at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will complete a file for staff Jonathan and will send copies of the completed file to LPA via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 11/18/2022 03:55 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/18/2022 at 03:25 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: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 staff not having proof of current required annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will provide LPA proof of required annual training to LPA via email by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 staff not having proof of current required annual training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will provide LPA proof of required annual training to LPA via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/18/2022 03:55 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/18/2022 at 03:25 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: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 staff had expired first aid/CPR training and 1 staff did not have proof of certification, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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Licensee will provide proof of certification for 2 staff to LPA via email by the POC due date.
Type B
Section Cited
CCR
87465(a)(9)
Incidental Medical and Dental Care Services
(9) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in the first aid kit not being complete and missing required bandages, scissors, and thermometer, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
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2
3
4
Licensee will obtained required items and send a picture of the purchase receipt for items and a picture of the items to LPA via email by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/18/2022 03:55 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/18/2022 at 03:25 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: 11/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(9)(A)
Incidental Medical and Dental Care Services
(9) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (9) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in a first aid manual was not available at the facility at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/19/2022
Plan of Correction
1
2
3
4
Licensee will print or purchase a first aid manual and provide a picture of the purchase receipt and book or a picture of the printed manual to LPA via email by the POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 of 3 residents with dementia did not have an updated medical assessment or reapparaisal, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2022
Plan of Correction
1
2
3
4
Licensee will obtain a new medical assessment and reappraisal for 2 residents with dementia and email copies of the documents to the LPA by the POC due date.
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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