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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700568
Report Date: 04/18/2023
Date Signed: 04/18/2023 06:01:26 PM

Document Has Been Signed on 04/18/2023 06:01 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
SACRAMENTO AC/SC, 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: 3DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Yacub LucasTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection on 04/18/2023 at 1:10 PM. LPA Lee met with licensee Yacub Lucas and explained the purpose of the visit. Licensee assisted with today’s visit.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has two public telephones one in the common area and one the kitchen area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve six (6) non-ambulatory residents with two (2) hospice waiver. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee observed sufficient seven-day non-perishable and two-day perishable food supplies. The resident bathroom water temperature measured at 131.9 degrees Fahrenheit which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Facility thermostat observed at 70 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee check MAR sheets along with medications and it was complete. First aid kit was incomplete; the first aid kit was missing a manual. Licensee purchased a new first aid kit from amazon today 04/18/2023 at 2:30 PM and showed purchased confirmation to LPA Lee. Licensee stated he will send pictures of the First Aid manual to LPA Lee when it arrives tomorrow. LPA Lee requested client and staff files for review.
Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CANTERBURY HOUSE
FACILITY NUMBER: 342700568
VISIT DATE: 04/18/2023
NARRATIVE
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LPA Lee reviewed (2) client files and (2) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks fingerprint cleared and associated to the facility. LPA Lee verified staff training for staff file reviews and learned that staff (S1) First aid/CPR has expired on 03/22/2023. The facility has infection control plan and has an emergency disaster plan.

The following documents were provided to LPA Lee during today’s visit:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Proof of Current Liability Insurance
(4) LIC 610 Emergency Disaster Plan

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/18/2023 06:01 PM - It Cannot Be Edited


Created By: Pang Lee On 04/18/2023 at 04:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CANTERBURY HOUSE
FACILITY NUMBER: 342700568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
87411(c)(1) Personal Requirements
(c)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as speified in Heatlh and Safety Code Sections 1569.625....(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Licensee did not ensure First Aid and CPR certificate was updated for S(1). First aid/CPR was expired on 03/22/2023 which poses an immediate health, safety or personal rights risk to resident in care.
POC Due Date: 04/21/2023
Plan of Correction
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Licensee will register for FIrst Aid/CPR class and send LPA Lee a copy of First Aid/CPR certificate by POC date of 04/21/2023 by 5:00 PM business day.
Type A
Section Cited
CCR
87465(8)(A)

87465(8)(A) Incidental Medical and Dental Care
(8) If a facility no medical unit on the grounds a complete first aid kit shall be maintained and be readily available in a specific location in the facility......(A) A current edition of a first aid manual approved by the American Red Cross......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. Licensee did not ensure that the first aid kit had a first aid manual which poses an immediate health, safety or personal rights risk to resident in care.
POC Due Date: 04/19/2023
Plan of Correction
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Licensee purchased a new first aid kid on 04/18/2023 at 2:30 PM. Licensee will send picture of the first aid kit manual to LPA Lee by POC date 04/19/2023 by 5:00 PM business day.
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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/18/2023 06:01 PM - It Cannot Be Edited


Created By: Pang Lee On 04/18/2023 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CANTERBURY HOUSE
FACILITY NUMBER: 342700568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
78303(e)(2) Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows....(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water......

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above to ensure that the water temperature was within the regulation of 105 degrees F to 120 degrees F. The water was measured at 131.9 which poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 05/01/2023
Plan of Correction
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Licensee adjusted the hot water temperature during today's visitate and LPA retested the water and it the temperature was measured 115.2. Licensee will send a water temperature log for the remaining month of April to LPA Lee by 05/01/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023


LIC809 (FAS) - (06/04)
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