<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 270708224
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:40:01 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/25/2023 and conducted by Evaluator David Ayers
COMPLAINT CONTROL NUMBER: 24-AS-20230725093000
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
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elvyra Abare - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident in care became severely dehydrated
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/13/2023, Licensing Program Analyst (LPA) D. Ayers conducted an unannounced complaint inspection. LPA met with Executive Director Elvyra Abare. The purpose of this visit is to deliver the finding of the investigation completed by the Department. LPA conducted a tour of the facility, interior and exterior to ensure there are no potential or immediate health and safety risk at the facility.

During the course of the investigation, the department inspected the facility, reviewed records, and conducted interviews. Resident 1(R1) was admitted to the facility on 2/20/2023. R1 was reassesed for a change of level in care by facility staff on 3/1/2023. At this time R1 was assessed as independent in the category of "Nutrition and Meals". On 7/17/2023, R1 was taken to the emergency room by paramedics due to collapsing while ambulating in the facility. According to the examining physician on 7/17/2023, the chief concern for R1 was hypotension. R1 was provided discharge instuctions for "dehydration" and "acute kidney injury". Based on the interviews conducted, documentation obtained and reviewed, and the information received during this investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated at this time.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 24-AS-20230725093000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CANTERBURY WOODS
FACILITY NUMBER: 270708224
VISIT DATE: 09/13/2023
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
26
27
28
29
30
31
32
Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited on LIC 9099-D. Failure to correct the deficiency may result in civil penalties.

An exit interview was conducted, and a copy of this report provided. Appeal Rights (LIC 9058) was provided to the administrator, whose signature below confirms receipt of these rights.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20230725093000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CANTERBURY WOODS
FACILITY NUMBER: 270708224
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2023
Section Cited
CCR
87463(f)(4)
1
2
3
4
5
6
7
87464 Basic Services: (f)(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator has stated that she will implement a hydration station in the assisted living dining room. Director of Health Services will revise safety check plan to include encouraging residents to take fluids.
8
9
10
11
12
13
14
Based on records review and interviews, the licensee did not ensure that 1 out of 25 assisted living residents received adequate personal assistance, resulting in 1 resident being treated for dehydration and acute kidney injury, which presents a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3