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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603774
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:19:03 PM


Document Has Been Signed on 04/04/2024 04:19 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 140DATE:
04/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Dave Hone/Executive DirectorTIME COMPLETED:
04:00 PM
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On 4/4/2024, Licensing Program Analysts (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Dave Hone / Executive Director. LPAs explained the purpose of today’s visit. The facility is licensed to serve (187) residents ages 60 and above, of which (15) may be bedridden only in building E, 2nd floor. Approved hospice waiver for (25). 1st floor all delayed egress memory care unit approved per code.

The facility consists of 5 building and have a Memory Care Unit, Assisted living, and independent living. The facility is 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 toured the physical plant with the administrator. There were no bodies of water or obstructions on the premises. A total of (10) rooms were inspected rooms: 106, 109, 111, A104, A102, A101, A308, A307 and A303. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA reviewed the last date the fire inspection company came to check the smoke detectors. The water temperature was measured adequately between 105F°—and 120 F°.

Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso IniguezTELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024
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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774
VISIT DATE: 04/04/2024
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During the visit, LPAs Iniguez observed the facility to be clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were observed. Cleaning agents and sharp objects were stored and inaccessible to residents in care. The kitchen was inspected, and sufficient perishable and non-perishable food was correctly maintained. All fire extinguishers were charged and were operable. A review of (7) residents' service files and (7) staff personnel files was conducted. (4) Medication Administration Records (MAR) were reviewed, and no discrepancies were found. The first AID kit was checked. The last fire disaster drill was on 3/19/2024.

LPA observed the facility's infection control practices. Liability insurance was provided to LPA. Facility Annual Fess are Current.

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


An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Dave Hone /Executive Director.

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

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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