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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708224
Report Date: 09/14/2021
Date Signed: 09/29/2021 07:14:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:CANTERBURY WOODSFACILITY NUMBER:
270708224
ADMINISTRATOR:ELVYRA ABAREFACILITY TYPE:
741
ADDRESS:651 SINEX AVENUETELEPHONE:
(831) 373-3111
CITY:PACIFIC GROVESTATE: CAZIP CODE:
93950
CAPACITY:190CENSUS: 147DATE:
09/14/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elvyra AbareTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime with Elvyra Abare Administrator, Helen Shi Program Clinical Consultant (PCC) and Jackie Jin Licensing Program Manager. The purpose of the visit was to provide technical assistance for Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a tour of the facility.

LPA and PCC reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, PPE usage, Doffing and Donning of PPE, and visitation.

The following recommendations were discussed:

1. Post Hand washing signs inside common area bathrooms.
2. Maintain Isolation Room PPE cart with supplies for immediate use.
3. Continue ongoing staff training on infection prevention and control measures.

LPA reviewed report with Elvyra Abare Administrator and copy emailed for signature.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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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