<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:32:37 PM

Document Has Been Signed on 09/12/2024 03:32 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BENTITS RETIREMENT VILLAFACILITY NUMBER:
198603173
ADMINISTRATOR/
DIRECTOR:		MARALIT, TERESITAFACILITY TYPE:
740
ADDRESS:1301 N BIRCHNELL AVETELEPHONE:
(626) 335-9598
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 4DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:Tita Bartolata, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) S Vaid conducted an annual required visit. LPA met with caregiver, Tita Bartolata and explained the reason for the visit. Caregiver Tita Bartolata, called Administrator, Administrator joined shortly after. LPA used the CARE tool to evaluate the facility. LPA inspected the physical plant, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and the plan has been 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 resident bathrooms were observed to have the required non-skid mats and grab bars. The bathroom basins with Jack and Jill sinks read 131.7degrees F which is not within the required 105 - 120 degrees- noted. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of 2-day perishable and 7-day non-perishable food, and the refrigerator in the garage. 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, for surveillance only, not recording. LPA observed a cabinet near the entrance of the laundry room to the right, that stored cleaning supplies/toxins and laundry supplies. Toxins and sharps are inaccessible to the residents.

LPA reviewed all resident files. Residents’ admission agreement, pre-admission appraisal, and proof of TB test. LPA reviewed staff files. Staff files contain health screening report, fingerprint clearance, certificates and trainings. LPA reviewed 4 residents' medications. Medications are documented properly and given as prescribed. First aid kit was observed and has all the required items and manual.
Continued on 809C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BENTITS RETIREMENT VILLA
FACILITY NUMBER: 198603173
VISIT DATE: 09/12/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Per California Code of Regulations, Title 22, the deficiencies observed are documented on the attached LIC809-D.

An exit interview was conducted, and a copy of the report, LIC 809, LIC 809C and LIC 809D and appeal rights were provided to Administrator.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/12/2024 03:32 PM - It Cannot Be Edited


Created By: Sanjay Vaid On 09/12/2024 at 02:50 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: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(3)
(e) Water supplies and plumbing fixtures shall be maintained as follows;(3) fawcets used by residents for personal care such as grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by the residents to attaina temperature of not less that 105 degrees F(41 degrees C) and not more than120 degrees F(49 degreesC)

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 water temperature measuring 131.7 and 130.6 in bathroom #1 with Jack and Jill basins which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
1
2
3
4
Administrator will adjust the water temperature within the required limits of 105 F -120 F by the due date. A temperature log will need to be completed for the following 7 days and submitted to LPA via email by 09/20/24.
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:Sanjay Vaid
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3