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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708224
Report Date: 06/20/2023
Date Signed: 06/20/2023 03:21:46 PM


Document Has Been Signed on 06/20/2023 03:21 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 140DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Elvyra AbareTIME COMPLETED:
03:30 PM
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LPA Shawna Doucette arrived at the facility unannounced to conduct a Case Management regarding an incident that was reported on 06/15/23 by Administrator Elvyra Abare. LPA met with Administrator.

LPA interviewed Administrator. LPA obtained copies of staff file. LPA obtained copies of R1's file. LPA will request copy of police report and medical records regarding this incident. LPA will return at a later date if necessary regarding this incident.

And exit interview was conducted and a copy of this report was provided to the Administrator.


SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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