198603177-8-19-2023-11-AS-EDAT-CUUUYW-20230819160037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603177
Report Date: 08/19/2023
Date Signed: 08/19/2023 04:23:27 PM

Document Has Been Signed on 08/19/2023 04:23 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:	08/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Jose Umana& Elsa Roman		TIME COMPLETED:	12:37 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 08/19/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met administrators Jose Umana and 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 adults ages 60 and above. Currently, the facility has (1) hospice resident in care. The facility is approved for (2) hospice resident. 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 114.8 degrees F. A comfortable temperature of 75 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. (Evaluation Report continues LIC 809-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023

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 08/19/2023 04:23 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: 08/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited. LPA identify resident #1 (R1) did not not have a current medical nor appraisal assessment. The last med/appraisal assessment is dated 2021. This violaton which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/09/2023
	Plan of Correction
1 2 3 4	Licensee will ensure to adhere to Title 22 87705 and submit a current medical and appraisal for resident #1(R1). Proof of correction must be sent to LPA Dabuet at ernand.dabuet@dsss.ca.gov by 09/09/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023

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: 08/19/2023

NARRATIVE

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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 the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 07/14/23. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 02/01/23 through 02/01/24.

An audit of resident #1-#6 (R1-R6) service files and staff #1-#6 (S1-S6) personnel files. Interviews were conducted with (5) residents and (2) staff. The facility has the current administrator's certification on file for Elsa Roman #6040880740 Expiration 06/23/24. The facility is not current on (CCL) license dues and an invoice was provided.

DEFICIENCY:

Records revealed resident #1(R1) diagnsosed with dementia does not have a current medical assessment and appraisal. The last medical/appraisal is dated 04/08/21 and 04/14/21.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Jose Umana and 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 Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2023

LIC809 (FAS) - (06/04)

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