198603177-8-6-2022-11-AS-EDAT-CH383D-20220806220921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603177
Report Date: 08/06/2022
Date Signed: 08/06/2022 10:10:55 PM

Document Has Been Signed on 08/06/2022 10:10 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:	CANTON COTTAGE		FACILITY NUMBER:	198603177
ADMINISTRATOR:	ROMAN, ELSA		FACILITY TYPE:	740
ADDRESS:	5221 E CANTON ST		TELEPHONE:	(818) 606-6136
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90815
CAPACITY:	6	CENSUS: 6	DATE:	08/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Yesnia Diaz & Elsa Roman		TIME COMPLETED:	04:55 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	On 08/06/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the CARE Inspection Tool. LPA met with administrator Elsa Roman and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory of which (1) may be bedridden elderly residents ages 60 and above. The facility is approved for (2) hospice residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) residents' rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area. LPA toured the physical plant. There were no obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of the visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured 110.6 F. A comfortable temperature of 74 degrees was maintained in the facility. LPA observed the facility to be appropriately furnished at the time of the visit. Storage areas for personal hygiene and objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (1) fire extinguisher that is charged, and smoke detectors operable. A working landline telephone remains available. The medication administration record (MAR) was reviewed and found to be accurate and maintained in order. Evaluation Report continues on LIC 809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022

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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Document Has Been Signed on 08/06/2022 10:10 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CANTON COTTAGE	FACILITY NUMBER: 198603177
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above in cleaning solutions and other hazardous materials were found under the bathroom sink in an unlocked cabinet. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87309. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/07/22 proof of chemicals and cleaning solutions are stored in locked cabinets. This violaton was corrected during visit.

Type A

Section Cited

CCR

87309(a)(1)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on (observation), the licensee did not comply with the section cited above LPA identifed sharp knives under the kitchen sink and inside the dishwasher accesible to reisdent in care not stored in locked storage. This violation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2022
	Plan of Correction
1 2 3 4	The licensee will adhere to Title 22 Section 87309. The licensee will perform knowledge of and conform to applicable laws, rules, and regulations. Plan of correction will be submitted by POC due date: 08/07/22 proof of sharp objects that pose danger to residents in care are stored in locked cabinets.

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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CANTON COTTAGE	FACILITY NUMBER: 198603177
	VISIT DATE: 08/06/2022

NARRATIVE

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INFECTION CONTROL:
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. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff tests and residents' vaccination along with daily temperature checks were conducted. The facility has an approved Mitigation Plan Report on file with CCLD. The facility has submitted Infection Control Plan for 2022 with CCLD.

DEFICIENCIES:
LPA identified at 1:51 pm knives under the kitchen sink were exposed in an unlocked cabinet. At 1:52 pm LPA identified (2) knives inside the dishwasher. At 1:54 pm, LPA identified cleaning solutions and other hazardous materials under bathroom sink #2 in an unlocked cabinet and accessible to residents in care.

Deficiencies are issued and an exit interview is conducted with Elsa Roman. A copy of this report is provided along with the appeal rights.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2022

LIC809 (FAS) - (06/04)

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