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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191603774
Report Date: 03/28/2025
Date Signed: 04/04/2025 09:06:10 AM

Document Has Been Signed on 04/04/2025 09:06 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CANTERBURY, THEFACILITY NUMBER:
191603774
ADMINISTRATOR/
DIRECTOR:		DAVE HONEFACILITY TYPE:
741
ADDRESS:5801 WEST CRESTRIDGE ROADTELEPHONE:
(310) 541-2410
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90274
CAPACITY: 187CENSUS: 147DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:David HoneTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 03/28/2025 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced annual required visit using the CARE Inspection Tool. CCLD staff met with Administrator David Hone and explained the purpose of today’s visit. The facility is licensed to serve a maximum 187 non-ambulatory residents of which 15 may be bedridden. Bedridden only in building E, 2nd floor. Ages 60 and above. Approved hospice for 25 clients. First floor all delayed egress memory care unit.

The facility consists of 5 buildings 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 tables and chairs.

CCLD staff and Administrator toured the physical plant. Rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational, . A comfortable temperature was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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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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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Document Has Been Signed on 04/04/2025 09:06 AM - It Cannot Be Edited


Created By: Jose Anguiano On 03/28/2025 at 04:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviews, the licensee did not comply with the section cited above: the licensee did not request a transfer of S3's criminal record clearence prior to working, this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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The licensee agreed to create a plan to ensure compliance with Title 22 87355(e) Criminal Record Clearance and associate S3's criminal record clearance. Proof of correction will be emailed to jose.anguiano@dss.ca.gov by POC due date.
Type B
Section Cited
CCR
87303(e)(2)

Maintenace and Operation. Water supplies and plumbing fixtures shall be maintained as follows. Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above: The hot water temperature in rooms E211, E203, and C302 tested between 122-123 F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2025
Plan of Correction
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The Maintenance staff adjusted the water temperature to 115 F during the visit. The licensee agreed to create a plan to ensure compliance with Title 22 87303(e)(2) Maintenance and Operation. Proof of correction will be submitted to jose.anguiano@dss.ca.gov by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Jose Anguiano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CANTERBURY, THE
FACILITY NUMBER: 191603774
VISIT DATE: 03/28/2025
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu.

LPA conducted an audit of 5 resident records, and 5 personnel records. The facility is current in CCLD annual license fees. The administrator certificate for is valid. The facility has a Liability Insurance Certificate valid through 01/01/2026.

The following deficiencies were observed during today’s visit : The hot water temperature measured between 122-123 degrees F in rooms E211, E203 and C302. Caregiver S3's Criminal Record Clearance was not transferred to the facility.

Title 22, Division 6 Chapter 8 is being cited please see LIC809D.

An exit interview conducted, and plans of corrections were developed with Dave Hone. A copy of the report and appeals rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Jose Anguiano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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