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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198201889
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:42:58 PM

Document Has Been Signed on 06/19/2025 12:42 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:SUMMERLAND MANORFACILITY NUMBER:
198201889
ADMINISTRATOR/
DIRECTOR:		BIENVENIDO M. CADUNGOGFACILITY TYPE:
740
ADDRESS:17708 CRENSHAW BLVETELEPHONE:
(310) 329-0799
CITY:TORRANCESTATE: CAZIP CODE:
90504
CAPACITY: 6CENSUS: 4DATE:
06/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:36 AM
MET WITH:Bienvenido 'Bien' CadungogTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 06/19/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator, Bienvenido ‘Bien’ Cadungog, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve six (6) elderly residents ages 60 and above, five (5) of which may be non-ambulatory and one (1) bedridden. The facility has an approved hospice waiver for three (3) residents. There are currently one (1) resident receiving hospice services.
Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident room, staff room, two (2) common bathrooms, living area, dining area, kitchen, attached garage, and an outside patio area. LPA inspected the facility with Administrator. LPA did not observe any bodies of water on the premises. All walkways around the facility were observed clean, clear, and free of obstructions, hazards, and debris.
Bedrooms LPA inspected all resident rooms and observed them to be clean and in good repair. LPA observed all rooms have the required items including a bed, dresser, chair, nightstand, and storage space for resident’s personal belongings. All beds were observed with the required linens including a mattress cover, fitted sheets, blankets, comforter, and pillows. LPA observed an ample supply of bed linens in good repair. All bedrooms were observed with adequate lighting.
Bathrooms LPA inspected all bathrooms and observed them to be within Title 22 regulations and were clean and operational. LPA observed all safety handrails are secured, and showers have nonskid mats and shower chairs. LPA observed an ample supply of bath towels stocked during the time of the visit. LPA observed an ample supply of hygiene products stored and inaccessible to residents. The water temperature measured 105.6-degrees and 105.7-degrees Fahrenheit.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2025
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 4
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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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: SUMMERLAND MANOR
FACILITY NUMBER: 198201889
VISIT DATE: 06/19/2025
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Kitchen LPA inspected the kitchen and observed it to be clean and sanitary. All appliances are operable and in good repair. LPA observed an ample supply of cookware, dining ware, and cutleries in good repair. LPA observed a 3-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored. LPA observed cleaning supplies secured in a cabinet under the kitchen sink and are inaccessible to residents. Sharps and knives are secured in a locked drawer and are in accessible to residents. The water temperature measured 106.4-degrees Fahrenheit.
Common Areas LPA observed the dining room has a large table with chairs to accommodate all residents. LPA observed in the living room are two (2) large couches and two (2) chairs available for resident use. The facility was observed to be sanitary and appropriately furnished at the time of visit. LPA observed reading material, games, and activities available for residents. LPA observed the fireplace is screened and inaccessible to residents. All walkways and hallways in the facility were observed clean, clear, and free of obstructions and hazards. All rooms and hallways were observed with ample lighting. The facility was maintained at a comfortable temperature.
Medications LPA observed medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA observed medication in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for four (4) residents. LPA observed four (4) out of four (4) resident’s medications are consistent with properly documented records.
Files LPA observed resident files are secured in locked cabinet and are inaccessible to residents and visitor. LPa reviewed the files for four (4) residents. LPA observed four (4) out of four (4) residents files contain the required documents. LPA reviewed the files for the Administrator and two (2) caregivers. LPA observed they had the required documents, certification, and training. The Administrator’s certificate is valid till 03/11/2027. LPA observed during file review the facilities Licensing Fees are current.
Safety LPA observed smoke and carbon monoxide detectors are operable. LPA observed two (2) fully charged fire extinguishers lasted serviced on 10/22/2024. The last fire prevention was conducted by the Torrance Fire Department on 02/11/2025. The last emergency drill was conducted 04/11/2025. LPA reviewed the facility’s liability insurance through South Bay Acceptance Corporation that is valid till 09/19/2025. LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E) that was last updated on 03/01/2025. LPA inspected the First Aid kit and observed it contained the required items and a current manual. The facility has an operational landline telephone. All exits are marked with an EXIT sign. All doors have an alarm that chimes when a door exiting the facility is opened. LPA observed all required postings posted in the hallway and dining room of the facility.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUMMERLAND MANOR
FACILITY NUMBER: 198201889
VISIT DATE: 06/19/2025
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Infection Control During the visit, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the entrance of the facility that has a visitor log, hand sanitizer, thermometer, and masks. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA observed all required infection control signs were posted in the facility.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Administrator, Bienvenido Cadungog, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC809 (FAS) - (06/04)
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