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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700568
Report Date: 05/11/2022
Date Signed: 05/11/2022 11:33:36 AM

Document Has Been Signed on 05/11/2022 11:33 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CANTERBURY HOUSEFACILITY NUMBER:
342700568
ADMINISTRATOR:LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:2052 CANTERBURY RDTELEPHONE:
(916) 565-1203
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 6CENSUS: 4DATE:
05/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Yacub LucasTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Anthony Tuck arrived to conduct an unannounced annual/random inspection on 0511/2022. LPA met with Yacub Lucas and explained the purpose of the visit. Yacub Lucas is the Administrator and holds certificate #6051257740 and expires on 02/20/2023

This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at (115) degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 09/08/2021 Thermostat observed at (73) degrees Fahrenheit.

LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident medication logs. LPA reviewed Fingerprint clearance and associations to the facility. First aid kit was checked and is complete.

The following forms need updating and were submitted to CCLD on 05/11/2022:
LIC 610E, LIC 500, LIC 9020, liability insurance certificate

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were found during today's visit. Exit interview held with Yacub Lucas and a copy of report given at the conclusion of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Anthony Tuck
LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2022
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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