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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:04:39 PM

Document Has Been Signed on 11/17/2023 03:04 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: 3DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tita Bartolata- CaregiverTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Caregiver, Tita Bartolata, and explained the purpose for the visit.
During today's visit, LPA Maldonado conducted a tour of the physical plant with Caregiver, Tita, observed the facility food supplies, reviewed (3) resident medications, (3) resident files, (4) staff files, and conducted interviews with (2) staff and attempted interviews with (3) residents. The facility is a single-story home, operating as an Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. It has an approved dementia care plan. There is a fire clearance approved for (6) non-ambulatory residents, of which (1) may be bedridden, and has a hospice waiver approved for (2). There are currently no residents receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility does not have a current Liability Insurance Policy in place. Per the Licensee/Administrator, Teresita Maralit, the policy has expired and is in the process of applying for a new policy with a different company.
The facility consists of (4) resident bedrooms, (1) live-in staff bedroom, (2) resident bathrooms, (1) staff/visitor bathroom, 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. LPA observed the following in bedroom# 3: the smoke detector was opened and did not have batteries- inoperable, damage to the ceiling which appeared to be cracked and paint is chipping, and the wall to the right side of the entrance was scuffed and had paint scratched off. Bedroom# 2 was toured and LPA observed that the emergency exit leading to the outside was locked by key from the inside, which does not allow for quick exit in case of an emergency. LPA also observed the front entrance door locked by key, from the inside. The facility does not have a fire clearance approved for locked perimeters/exterior doors.
(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
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: 11/17/2023
NARRATIVE
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 Per staff, they have been instructed to lock this door due to Resident# 3 (R3) wandering and staff afraid of R3 walking out of the facility. Staff unlocked and opened the door. LPA observed that the auditory device at the door was inoperable. Auditory devices at all other entrances/exits were also observed to be inoperable and one was missing at the sliding door in the TV room. Full bed rails were observed on Resident# 1's (R1) bed, without written physician's orders in R1's file, indicating the need for the bed rails. Per staff, R1 was recently discharged from Hospice but is still using the hospital bed. Resident 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 left side was observed to have a sign indicating "Pls don't use this side. It's leaking. Thanks" LPA opened the faucet and observed water leaking from underneath the sink, into a small bucket. The resident bathrooms were observed to have the required non-skid mats and grab bars. The hot water was tested and measured between 140*F- 144*F. 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 cabinets underneath the kitchen sink to be broken. There are pieces of wood placed on the floor holding the cabinet up, and the top of the cabinet is hanging down. Caregiver stated Licensee is aware of the broken cabinet. All sharps were observed to be stored and inaccessible in a drawer next to the kitchen sink. Cleaning supplies/toxins and laundry supplies are stored in a cabinet in the laundry room, inaccessible to residents. Several fire extinguishers were observed throughout the facility with recent inspections and were fully charged. LPA observed several cameras in the facility, located in the hallway and common areas only. The smoke/carbon monoxide detectors were tested and operational.

After review of resident files, LPA discovered that files for (3) of (3) residents were missing Pre-Admissions Appraisals and Needs and Services Plans. Files for R2 and R3 were missing records for residents cash resources/personal property/valuables and Functional Capabilities Assessments. After review of staff files, it was discovered that (3) of (4) staff did not have a personnel file in the facility to review, which includes the Administrator/Licensee's file. LPA also discovered that (2) of (4) staff were not associated to the facility, but had proper criminal background clearance. LPA reviewed (3) residents' medications and observed them to be documented properly and given as prescribed.


(Report Continued on LIC809-C...)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 11
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: 11/17/2023
NARRATIVE
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During today's visit, LPA observed R3 attempting to open the front entrance door several times, attempting to walk away and wander off while staff were tending to other residents. LPA also observed visitors of other residents attempting to provide care/supervision to R3 during their visit, by calling R3 back every time R3 attempted to walk away and asking R3 to sit and stay there while caregivers were tending to the other residents. LPA determined that there is insufficient staff to care for residents with dementia and wandering behaviors. After speaking with Licensee/Administrator, she informed LPA that she is at the facility about 3-4 hours a day, 3-4 times per week to oversee the operations of the facility. Due to deficiencies cited today, repeat violations observed, LPA determined the administrator is not on the premises sufficient hours to permit adequate attention to the administration of the facility.

Per California Code of Regulations, Title 22, deficiencies were observed and are cited on the attached LIC809-D.

Additionally, Civil Penalties in the amount of $1,900.00 were assessed and issued during today's visit due to repeat violations within a 12-month period, as well as caregivers working at the facility without proper association to the facility, and violation of fire clearance.

An exit interview was conducted and a copy of this report and appeal rights were provided to caregiver, Tita Bartolata. Licensee was also phoned, and citations and civil penalties were discussed.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 admitting to have an expired liability insurance policy, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
1
2
3
4
Licensee has submitted proof of the application in process with the new insurance company. LPA has advised licensee to submit new insurance policy to LPA, via email, once obtained.
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(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, the licensee did not comply with the section cited above in the hot water temperature measuring between 140*F-144*F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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Licensee will adjust water temperaure immediately to bring to compliance. A water log will be completed for the following 5 days and submit 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

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 4 staff missing proper association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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Licensee will submit Request for Transfer of 2 staff, including criminal background clearance, to LPA via email, by POC due date. Staff will need to be immediately removed from the facility until documentation is provided.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in auditory devices at all entrances/exits inoperable/missing, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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Licensee will repair/replace auditory devices and submit proof of purchase/pictures of installation to LPA via email, by 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(2)
Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in the front entrance door and resident room# 2 emergency exit door locked by key, from the inside, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2023
Plan of Correction
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Licensee will submit a written plan on how the facility will comply with providing care/supervision to residents with dementia and wandering behaviors, without locking the doors to prevent residents from leaving, to LPA via email, by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in kitchen sink cabinet is broken and falling apart, visitor/staff bathroom sink leaking, bedroom# 3's wall is scuffed and paint is chipped, and the ceiling is cracked, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will make reparations required and submit work receipts and pictures of the corrections to LPA, via email, by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

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
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in havng insufficient staff to provide services/care needed to meet resident needs, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will submit written plan indicating how they will ensure there is sufficient staff at all times to meet the needs of residents in care, to LPA via email, by 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 4 staff files unavailable for licensing to audit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will submit written plan to LPA via email, on how they will comply with maintaining personnel records for all staff/volunteers at the facility at all times.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in R2 and R3's files were missing records of resident's cash resources/personal property/valuables, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will submit records of resident's cash resources/personal property/valuables for R2 and R3, to LPA via email, by 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (A) Section 87457, Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 3 residents missing Pre-Admissions Appraisal in their file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will provide a copy of Pre-Admission's Appraisal for 3 residents in care, to LPA via email, by POC due date.
Type B
Section Cited
CCR
87506(b)(17)(B)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (B) Section 87459, Functional Capabilities;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 of 3 residents missing the Functional Capabilities Assessment in their file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will submit a copy of R2 and R3's Functional Capabilties Assessment, to LPA via email, by 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 11/17/2023 03:04 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 11/17/2023 at 02:03 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(D)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information requried by the following: (D) Section 87462, Social Factors;

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 3 residents missing Needs and Services Plan on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee to submit a Needs and Services Plan for 3 residents in care, to LPA via email, by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in R1 having full bed rails without proper physician's orders indicating the need for them, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
1
2
3
4
Licensee will obtain written physician's orders for R1, indicating the need for full bed rails. Orders will be emailed to 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: 11/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023


LIC809 (FAS) - (06/04)
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