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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700568
Report Date: 05/09/2025
Date Signed: 05/09/2025 12:52:17 PM

Document Has Been Signed on 05/09/2025 12:52 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CANTERBURY HOUSEFACILITY NUMBER:
342700568
ADMINISTRATOR/
DIRECTOR:		LUCAS, YACUBFACILITY TYPE:
740
ADDRESS:2052 CANTERBURY RDTELEPHONE:
(916) 565-1203
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 6CENSUS: 4DATE:
05/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Lucas YacubTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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
Licensing Program Analyst (LPA) Holly Williams arrived unannounced to conduct an annual inspection. LPA Williams met Facility Designated Administrator (FDA) Lucas Yacub and a brief interview was conducted.

LPA Williams reviewed four resident files (R1-R4) and two staff files (S1-S2). The census is 4 residents and the facility has a hospice waiver for 6.
LPA Williams toured the facility with the FDA and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 120 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.
LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. While touring the facility LPA observed medication in 3 out of the 4 residents rooms. LPA observed the medication cart unlocked and pre poured medication in the medication cart and pre poured medication in the unlocked drawer in the kitchen. LPA Williams observed unlocked cabinets for the storage of cleaning solutions and knives in the kitchen, unlocked cleaning solutions in the 2 out of 3 bathrooms. In the 2 laundry rooms LPA observed unlocked detergent and rat poisons.
LPA Williams interviewed staff member (S1) and 2 resident (R1-R2).
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal rights were printed and a copy was given to the facility designated Administrator at this time.
Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Holly Williams
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
Document Has Been Signed on 05/09/2025 12:52 PM - It Cannot Be Edited


Created By: Holly Williams On 05/09/2025 at 11:36 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CANTERBURY HOUSE
FACILITY NUMBER: 342700568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

Deficient Practice Statement
1
2
3
4
This requirement was not met as evidenced by:
Based on observation, the licensee did not ensure that all poisons, knives, cleaning supplies, and detergents in 2 of the 2 laundry rooms were inaccessible to residents and locked up which poses an immediate health and/or, safety, and personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
1
2
3
4
Licensee agrees to conduct a 1 hour training on storage of knives and poisons within 1 week of the POC due date. Licensee agrees to email a plan of action and a statement of understanding of the regulation above to the LPA with in 24 hours of the annual visit. The plan of action will include the subject material of the training and the sign in sheet. Holly.Williams@dss.ca.gov
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Deficient Practice Statement
1
2
3
4
This requirement was not met as evidenced by:
Based on observation, the licensee did not keep medications locked up and inaccessible to residents which poses an immediate health and/or, safety, personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
1
2
3
4
Licensee agrees to conduct a 1 hour training on storage of medication with in 1 week of the POC due date. The licensee will send a statement of understanding to the LPA about the regulation and a plan for training BY the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Holly Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 05/09/2025 12:52 PM - It Cannot Be Edited


Created By: Holly Williams On 05/09/2025 at 11:37 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CANTERBURY HOUSE
FACILITY NUMBER: 342700568

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

Deficient Practice Statement
1
2
3
4
This requirement was not met as evidenced by:
Based on observation, the licensee did not keep medication in its originally stored container which poses an immediate health and/or, safety, personal rights risk to persons in care.
POC Due Date: 05/10/2025
Plan of Correction
1
2
3
4
Licensee agrees to conduct a 1 hour training on medication administration within a week of the POC due date. Licensee will send the LPA the subject material of the training and the sign in sheet within one week of the POC due date. Licensee agrees to send a statement of understanding of the regulation cited above and the plan for training BY the POC due date. Holly.Williams@dss.ca.gov
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Holly Williams
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4