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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603177
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:19:15 PM


Document Has Been Signed on 06/13/2024 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: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: 5DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jose Umana, AdministratorTIME COMPLETED:
04:31 PM
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On 06/13/2024 Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA was met by Edgar Yraheta, Administrator Assistant, and the purpose of today's visit was explained. The facility is licensed to operate for (6) non-ambulatory, of which (1) may be bedridden, elderly adults ages 60 and above. Currently, the facility has five (5) residents and zero (0) hospice residents in care. 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: (4) residents' rooms, (2) bathrooms, a living area, a dining area, a kitchen, an outside seating area, and a garage utilized for storage.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 117.2 degrees F. A comfortable temperature of 77.0 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguishers were charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete.


Report continues, see LIC809C.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: CANTON COTTAGE
FACILITY NUMBER: 198603177
VISIT DATE: 06/13/2024
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 04/18/2024 and earthquake drill on 05/20/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 02/01/24 through 02/01/25.

There have been no deficiencies cited today.

An exit interview was conducted with Edgar Yraheta, Administrator Assistant, and a copy of this report have been provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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