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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 270708224
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:36:25 PM

Unsubstantiated


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):
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Staff did not ensure resident in care had clean clothing
Resident's hygiene needs were not properly met
Staff did not ensure facility was free of pests
Resident was not provided proper food service
INVESTIGATION FINDINGS:
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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, conducted interviews, and reviewed records. Resident 1(R1) was admitted on 2/20/2023. As part of R1's Service Agreement(contract), laundry service was provided weekly. Based off of interviews, R1 regularly declined assistance with showers, and would tell facility staff that she was clean. Based on a physician's assessment dated 7/6/2023, R1 was able to bathe and groom themself with reminders. Staff observed ants in the apartment of R1. After observing ants, staff applied "Ant Advion" and placed a work service order to spray for the ants on 6/15/2023. R1 kept two cats as pets in her apartment. R1 was assessed as independent in the category of food and nutrition. Three meals and snacks were made available to R1 on a daily basis, and staff observed R1 to regularly attend meals in the dining room. During inspection, facility food service appeared to be of adequate quality and quantity, and snacks were availble for residents in both common and personal refrigerators.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 2
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
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2