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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708224
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:12:23 PM


Document Has Been Signed on 09/13/2023 03:12 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
SIERRA CASCADE AC/SC, 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: 144DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elvyra Abare - Executive DirectorTIME COMPLETED:
02:30 PM
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On 9/13/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced to conduct a Required Annual Inspection. LPA met with Executive Director Elvyra Abare and announced the purpose of the visit. Administrator Certification is current with renewal date 7/10/2024.

LPA toured the facility inside and outside. All passageways and exits were clear and free from obstruction. Fire extinguishers were recently serviced and facility has a sprinkler system. Facility regularly conducts emergency drills in cooperation with local fire authority. LPA toured the facility kitchen and observed an adequate supply of perishable and non-perishable foodstuffs. Kitchen and all common areas were clean, well-lit, and odor-free. Facility had adequate supply of emergency food and first aid supplies. LPA reviewed emergency-disaster plan. LPA toured a sample of resident bedrooms and bathrooms, which were observed to be clean, with all fixtures and appliances functioning properly. Bathrooms were clean and were equipped with required grab-bars and non-skid mats. LPA observed centrally stored medications in assisted living to be properly stored and secured, and medications appeared to be administered properly. Narcotic medications were secured in a locked canister within the medication cart and all doses were recorded. LPA reviewed a sample of resident and staff files. Files contained required documentation and records. LPA requested the following files to be provided to CCLD by 9/20/2023: LIC 500, LIC 308, LIC610E, and LIC 9020a.

No deficiencies were cited during the inspection. A copy of the report was provided and exit interview conducted with Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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