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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603177
Report Date: 08/28/2023
Date Signed: 08/28/2023 07:39:42 PM


Document Has Been Signed on 08/28/2023 07:39 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:CANTON COTTAGEFACILITY NUMBER:
198603177
ADMINISTRATOR:ROMAN, ELSAFACILITY TYPE:
740
ADDRESS:5221 E CANTON STTELEPHONE:
(818) 606-6136
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 6DATE:
08/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kristen PriscoTIME COMPLETED:
03:45 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 08/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregiver Kristen Prisco and explained the purpose of the visit.

During a required annual inspection visit on 08/19/223, LPA and was informed that staff #2 and #6 had the required TB test and staff #4 had the required CPR/First Aid certificate completed and just did not have it included in the personnel files. The administrator failed to submit proof of completed for staff #2, #4 and #6 by agreed due date 08/21/23.

The licensee violated 87458 Personnel Records and 87411 Personnel Requirements General Title 22 Regulations.

California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).


An exit interview conducted with Kristen Prisco a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
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


Document Has Been Signed on 08/28/2023 07:39 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: CANTON COTTAGE
FACILITY NUMBER: 198603177

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2023
Section Cited
CCR
87458(a)(1)

1
2
3
4
5
6
7
87412 Personnel Records (a)The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:(11) A health screening as specified in Section 87411.
1
2
3
4
5
6
7
Licensee shall ensure all residents conduct a health screening for TB. Licensee also agreed to have test results as proof of correction and will be submitted to CCLD by 09/11/23 to ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on record review, the licensee failed to staff #2&#6 (S2) & (S6) had health screening for TB. This violation possesses a potential Health or Personal Rights risks to residents.
8
9
10
11
12
13
14
Type B
08/28/2023
Section Cited
CCR87411(c)(1)

1
2
3
4
5
6
7
87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
1
2
3
4
5
6
7
Licensee shall ensure staff #4 will complete First Aid/CPR training. Licensee also agreed to have results as proof of correction and will be submitted to CCLD by 09/11/23 to ernand.dabuet@dss.ca.gov
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on record review, the licensee failed to ensure staff #4 (S4) had First Aid/CPR completed. This violation possesses a potential Health or Personal Rights risks to residents.
8
9
10
11
12
13
14
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: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2