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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204938
Report Date: 11/11/2020
Date Signed: 05/19/2021 06:24:39 AM

Document Has Been Signed on 05/19/2021 06:24 AM - 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 DR #100
MONTERY 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: 4DATE:
11/11/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:02 AM
MET WITH:Arlene Feliciano & Virginia FelicianoTIME COMPLETED:
11:26 AM
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On 11/11/20 Licensing Program Analyst, LPA/Ernand Dabuet conducted a Case Management visit at this facility. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted through FaceTime with Arlene Feliciano/Administrator. LPA explained the purpose of the visit was to conduct a health and safety inspection.

LPA was met by Arlene Feliciano/Administrator who allowed for LPA's entry for a virtual tour. LPA conducted a walk-through of the entire facility interior/exterior. The facilities consist of (6) resident bedrooms, (2) bathrooms, a living room, dining room, and kitchen and activity room. Resident bedrooms had the required furniture, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms are clean, sanitary and fixtures are working properly. Bathrooms grab bars are secure and non-skid mats in place. Common areas were free from obstruction. Fire extinguishers are fully charged. Carbon Monoxide and smoke alarms were tested and are working correctly.

Food service and the kitchen were checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. LPA observed no hazardous cleaning/toxic solutions and sharp accessible to residents. The medications were securely locked and inaccessible to residents in kitchen cabinets. The Medication Administration Records (MARS) were in order and complete. The First Aid kit and Personal Protective Equipment are fully stocked. Outside grounds were toured and no bodies of water were noticed. Walkways around the home were clear of hazards. LPA observed all mandated posters were posted and visible.

Evaluation Report continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/11/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: BRENT WOOD VILLA
FACILITY NUMBER: 198204938
VISIT DATE: 11/11/2020
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During the inspection, LPA observed (3) residents were fully active and (1) was sleeping. The residents were interviewed and report that all their needs and services are adequately satisfied. The Administrator states (1) resident is on hospice care.

LPA requested copies of the following documents to be submitted by email on later than 11/12/20 for review:
  • Current Staff Roster
  • Current Resident Roster
  • Current Emergency Disaster Plan
  • Proof of Liability Insurance

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued.

A telephonic exit interview was conducted with Arlene Feliciano and a hard copy was provided via email for signature.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 11/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/11/2020
LIC809 (FAS) - (06/04)
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