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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204938
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:52:47 PM


Document Has Been Signed on 10/27/2023 03:52 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:BRENT WOOD VILLAFACILITY NUMBER:
198204938
ADMINISTRATOR:KENNETH PITTSFACILITY TYPE:
740
ADDRESS:17004 ATKINSON AVENUETELEPHONE:
(310) 538-2284
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY:6CENSUS: 5DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:BIEN CADUNGOGTIME COMPLETED:
04:15 PM
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10/27/2023, Licensing Program Analyst (LPA) Antonine Richard conducted an unannounced annual required visit using the new CARE Inspection Tool. LPA met with administrator Bien Cadungog and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory elderly residents ages 60 and above. All five (5) residents are non-ambulatory.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: six (6) resident's rooms, two (2) common bathrooms, living area, dining area, kitchen, and outside covered patio area.

LPA and administrator toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The hot water temperature measured 109.10F degrees A comfortable temperature of 73 degrees was maintained in the facility. The last fire drill was 10/07/2023.

LPA observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. A fire extinguisher was charged, smoke detectors and carbon monoxide were operable. A review of Medication Administration Records (MAR) was maintained in order and accurate.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: BRENT WOOD VILLA
FACILITY NUMBER: 198204938
VISIT DATE: 10/27/2023
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings.

No deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Administrator Bien Cadungog.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonine RichardTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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