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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603173
Report Date: 11/07/2025
Date Signed: 11/07/2025 04:36:12 PM

Document Has Been Signed on 11/07/2025 04:36 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:
11/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:48 PM
MET WITH:Caregiver Evelyn ValeraTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual visit. LPA was met by caregiver Evelyn Valera and the purpose of the visit was explained. Administrator Teresita Maralit was advised telephonically.

The facility is licensed to serve residents age range 60 and over, approved for six (6) non-ambulatory of which one (1) may be bedridden. Approved hospice waiver for two (2). The facility is a single-story home located in a residential area of San Dimas. The home consists of four (4) resident bedrooms, one (1) staff room, two (2) resident bathrooms, one (1) staff bathroom, living room, dining area, TV room, laundry room, front and backyards.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

The front and backyard are well maintained and there are no pools or large bodies of water. Passageways and exits are free of obstructions.

Smoke detectors were observed throughout the facility and are operable. There is a carbon monoxide detector located in the hallway of the home, tested and not operable. Deficiency cited. There is a fire extinguisher located in the kitchen which was observed to be charged. Emergency drills conducted quarterly, last drill was August 2025.

continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 11/07/2025 04:36 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 11/07/2025 at 03:31 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: 11/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [1] out of [1] carbon monoxide detector located in the hallway was tested and not operable which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2025
Plan of Correction
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Licensee agreed to have maintance service the carbon monoxide detector. Licensee will send LPA video of the carbon monoxide detector being tested and operable by POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that cleaning solutions were observed unsecured on a countertop in the hallway accesible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/07/2025
Plan of Correction
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Corrected at time of visit. Caregiver stored cleaning solution in a secured cabinet located in the laundry, making them inaccessable to clients in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/07/2025 04:36 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 11/07/2025 at 03:31 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: 11/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed not a sufficient supply of fresh fruit or bread for a minimum of two days which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2025
Plan of Correction
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Licensee stated they are bring groceries tomorrow. Licensee will provide LPA proof in the form of photos of the food and photos of receipt as proof of purchase by POC due date.
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that LPA observed a pest trap on the kitchen counter top full of bugs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2025
Plan of Correction
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Licensee stated they have a contract with Terminx pest control services. Licensee will provide proof of contract and photos showing the countertop has been clean and full pest trap removed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 11/07/2025
NARRATIVE
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continued from LIC 809

Kitchen appliances are clean and were operating at the time of the visit. Sharps are secured in a kitchen drawer and are inaccessible to residents. Kitchen was clean but there was evidence of pests in the form of a pest trap containing dead bugs on the kitchen countertop. Deficiency cited. There was not a sufficient supply of two (2) days perishable food, LPA observed not enough fresh fruit or bread for residents in care. Deficiency cited. Sufficient supply for seven (7) days non-perishable foods were observed. Fireplace located in the living room was inaccessible with a covered screen. Games and puzzles observed in living room for resident use. Dining room and living room are clean and free of obstructions and have sufficient seating for residents in care. Resident bedrooms have the required furniture and have sufficient closet and storage space. Resident beds have the required linen and the linen is in good repair.

Washing machine and dryer were clean and operable at the time of visit. There is a locked cabinet in the laundry room with detergent, cleaning supplies and disinfectants, secured and inaccessible to residents in care. Cleaning solutions were observed unsecured on a countertop in the hallway accessible to residents in care. Caregiver secured cleaning solutions at time of visit, locking them in the laundry room. Deficiency cited.


Medications are centrally stored in a locked cabinet in the TV room. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual.

Three (3) resident and three (3) staff files were reviewed and were observed to contain required documentation. Facility file for resident #4 was mistakenly taken by EMS. Staff are awaiting resident’s family to retrieve file.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D.

Exit interview held and a copy of the report along with appeal rights were provided to the Caregiver Evelyn Valera.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC809 (FAS) - (06/04)
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