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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708224
Report Date: 09/29/2021
Date Signed: 09/29/2021 07:54:57 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: 144DATE:
09/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Elyvra AbareTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Elvyra Abare Executive Director. The census is 144 of which 22 residents reside in Assisted Living (AL).

LPA toured the facility inside and out to include entrance, lobby, main dining room, and exterior. In LPA inspected AL bedrooms, bathrooms, and dining area. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cart. Toxins, cleaning supplies, knives and sharp objects are secured.

At noon time LPA observed lunch service in AL to include minestrone soup and Florentine pasta salad with a chicken entrée. Alternative menu is available to residents.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to residents and visitors.

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, training, PPE usage and personal rights.

Designated staff have been Fit Tested. Facility held Flu vaccination clinic on 9/28/2021 and COVID 19 Booster Vaccination Clinic is scheduled for 10/18/2021.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Elvyra Abare Executive Director and a copy of this report emailed due to technical issues.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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