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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603774
Report Date: 04/12/2022
Date Signed: 04/14/2022 03:39:33 PM


Document Has Been Signed on 04/14/2022 03:39 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:CANTERBURY, THEFACILITY NUMBER:
191603774
ADMINISTRATOR:DAVE HONEFACILITY TYPE:
741
ADDRESS:5801 WEST CRESTRIDGE ROADTELEPHONE:
(310) 541-2410
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY:187CENSUS: 122DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Dave Hone, Executive DirectorTIME COMPLETED:
04:00 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) Ana Soto conducted an unannounced Annual required visit and an infection control inspection to the above facility. LPA was met by receptionist and later met with Dave Hone, Executive Director and the purpose of today’s visit was explained.

There are currently (122) residents in the facility. (119) residents are ambulatory and (3) are non-ambulatory. The facility consists of 5 building they have Memory Care, Assisted living, and Independent living. The facility is located in a residential neighborhood. It has (110) bedrooms, (126) 3/4 bathrooms, (12) common bathrooms, (2) laundry areas, Kitchen, kitchenettes & dining area, and lounges.

LPA and Dave toured the entire facility. Documents are posted as mandated. Room#'s A111, 109,103, A308 311, 312 302, A208, 205, 204, B303, 306, 315, B205, 209, 215, B107, 104, 103 are occupied by residents and contain the mandated furniture. No in living staff rooms. The (?) bathrooms are clean and operational. Smoke detectors and carbon monoxide detector were in compliance and operational. There are bodies of water present (main fountain in the middle of parking near main entrance and 3 water falls situated in the back walls in-front of brick wall next to main water fountain) which poses no hazard to residents. 15 fire extinguishers are fully charged. All building hallway are free of debris. The facility is in good condition. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged, and temperature checked, sanitizer/soap in all bathroom (common and private) and additional sanitation supplies (carts) are locked in the Health Services room. LPA observed staff wearing masks, residents’ private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The facility has an approved Mitigation plan. The resident’s temperatures are checked and logged once a day.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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


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
MONTEREY PARK, CA 91754
FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774
VISIT DATE: 04/12/2022
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
 PPE's are enough for 30 days and are locked in the basement of building B. The facility had one positive resident and failed to report it to CCLD. All staff has had all 3 vaccinations, 90% of residents also have all 3 vaccinations.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Dave Hone, Executive Director and a copy of Report and Appeal Rights provided

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 04/14/2022 03:39 PM - It Cannot Be Edited

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
MONTEREY PARK, CA 91754


FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
872119(a)(2)
87211(a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interviews, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
1
2
3
4
Executive Director to ensure that they report immediately any covid positive cases to CCLD,
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4