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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603774
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:32:56 PM


Document Has Been Signed on 02/23/2023 03:32 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, 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: 119DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Robin GordonTIME COMPLETED:
03:00 PM
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On 02/23/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced Annual required visit with the primary focus on infection control. LPA was met with Director of Environmental Services, Robin Gordon and Executive Director, Dave Hone, and the purpose of today’s visit was explained. LPA toured the facility with Director of Environmental Services, Robin Gordon.

There are currently 119 residents in the facility. The facility consists of 5 building and have a Memory Care Unit, Assisted living, and Independent living. The facility is located in a residential neighborhood. It has 98 independent living rooms, 18 assisted living rooms, 9 memory care rooms, 28 skilled nursing beds, 12 common bathrooms, 2 laundry areas, Kitchen, kitchenettes & dining area, activity area, lounges, and outdoor shaded patio areas with table and chair.

LPA and Robin toured the facility. LPA and Robin walked through rooms that were unoccupied and used as a model due to residents isolating for a Covid-19 outbreak. Robin informed LPA that residents bring their personal furnishings. LPA and Robin toured all common room areas. In all common rooms LPA observed ample seating and spacing for residents. LPA observed games, books and puzzles in lounge areas and activity areas. All common bathrooms observed were clean and operational. All building hallways were clear, clean, and free of obstructions, hazards, or debris. The facility is clean and in good repair. There are bodies of water present (main fountain in the middle of parking near main entrance and 3 waterfalls situated in the back walls in-front of brick wall next to main water fountain) which poses no hazard to residents.

All smoke detectors and carbon monoxide detectors are fully operational. The Automatic Sprinkler System was last serviced on 12/12/22. All fire extinguishers observed were fully charged and last serviced on 01/22/23. The last emergency drill was 02/08/23. All exits and staircases were visibly marked. LPA observed all required documents posted within the facility. LPA reviewed the Liability Insurance through Acord, which expires on 01/01/24.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2023
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774
VISIT DATE: 02/23/2023
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All smoke detectors and carbon monoxide detectors are fully operational. The Automatic Sprinkler System was last serviced on 12/12/22. All fire extinguishers observed were fully charged and last serviced on 01/22/23. The last emergency drill was 02/08/23. All exits and staircases were visibly marked. LPA observed all required documents posted within the facility. LPA reviewed the Liability Insurance through Acord, which expires on 01/01/24.

During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry. All visitors, staff, and resident’s temperatures are checked and logged. There are sanitizing stations throughout the facility. There is an ample supply of sanitizer/soap in bathrooms. LPA observed all staff, residents and visitors wearing masks. LPA observed PPE carts outside rooms of residents who are in isolation. All rooms have the appropriate zoning signs clearly posted. All residents were tested on 02/15/23 and retested on 02/21/23. LPA observed infection control signs posted throughout the entire facility. There is a 120-day supply of PPEs stored in the basement.

There are no deficiencies cited today.

An exit interview was conducted with Director of Environmental Services, Robin Gordon and Executive Director, Dave Hone a copy of Report was provided.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Wendy GibbsTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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