The Canterbury

Type of visit: Required - 1 Year

On 03/24/26 Licensing Program Analyst's (LPA's) Villegas and Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA's met with Executive Director David Hone as the purpose of today’s visit was explained. The facility is licensed to serve a maximum 187 non-ambulatory residents of which 15 may be bedridden. Bedridden only in building E, 2nd floor. Ages 60 and above. There is an approved hospice for 25 clients. First floor all delayed egress memory care unit. Facility annual fees info was provided (PIN # 080063 amount due $2,310 Due date: 03/31/26), liability insurance is active (Caring Communities Shared Services CCRRG-0032-26 exp: 01/01/2027). The facilities Administrator certificate for is current (7014902740 exp: 2/26/28) The facility consists of 5 buildings and have a Memory Care Unit, Assisted living, and independent living. The facility is in a residential neighborhood. It has 98 independent living rooms, 18 assisted living rooms, 9 memory care rooms, 28 skilled nursing beds, 12 common bathrooms, 2 laundry areas, Kitchen, kitchenettes & dining area, activity area, lounges, and an outdoor shaded patio areas with tables and chairs. 14 bedrooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational, storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained. The water temperature measured between 110 F- 113F.. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. Official inspection by the Los Angeles Fire Department was on 11/20/25. LPA conducted a review of (10) resident records, (10) Medication Records Administration (MAR), and (6) personnel records. No discrepancies were observed during today's visit. Exit interview conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Case Management - Other

On 12/12/25 Licensing Program Analyst (LPA) Mario Leon conducted a case management visit at the facility. LPA was met by staff one, Nicole Prescott - Director Health Services (S1) and the purpose of the visit was explained. The case management visit consisted of the following: LPA was unable to collect prospect one's (R1) documents, listed as follows; Hospital discharge Summary Physician’s Report (LIC 602), Any facility assessment (i.e., pre-placement assessment) Any pertinent medical records that may provide additional context or support for the resident’s current condition. R1's currently not a resident. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff two, Lorena Bautista - LVN Manager (S2) and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Dec 12, 2025

Allegation investigated: Staff did not repair resident's toilet in a timely manner

On 05/08/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at this facility to deliver findings regarding the above allegation. LPA met with staff nine Dave Hone Executive Director (S9), and the purpose of the visit was explained. On 04/11/25 LPA requested and reviewed facility documents, including the following: Resident roster (dated 04/10/25), staff roster (dated 04/11/25), and documentation of a call from a resident's room. LPA interviewed five (5) out of one-hundred and thirty-seven (137) residents (R1-R5), eight (8) out of two-hundred and ninety-one (291) staff (S1-S8) and one (1) witness. Investigation revealed the following: Regarding the allegation, "Staff did not repair resident's toilet in a timely manner", it has been alleged that a resident's toilet was left clogged for 16 hours. On 04/11/25 LPA observed a resident's room, which contains two restrooms. On 04/11/25 LPA interviewed staff five, Rene Cardoza (S5), maintenance supervisor, who confirmed the maintenance team works from 07:00AM to 4:00PM. Report continues, see LIC9099-C. Substantiated S5 also verified that maintenance staff follow their schedules based on an on-call maintenance staff rotation, indicating that there are on-call maintenance staff continuously available (24/7) to repair any malfunction at this facility. LPA interviewed staff six, Oziel Rodriguez (S6) maintenance staff, who confirmed that S6 repaired the toilet on 03/05/25 (time unknown). LPA interviewed staff seven, Richard Madridejos (S7), who explained that "If it’s a clogged toilet, we have to respond as soon as possible (ASAP)." and that "We don’t tell them to use another toilet in their room, or another toilet down the hall. We have to do that ASAP." On 04/11/25 LPA reviewed front desk call log that noted a resident, or their private caregiver, reported a clogged toilet in their room on 03/04/25 at 5:02PM. LPA reviewed a maintenance work order, noting that the same toilet was repaired on 03/05/25 at 09:13AM. This record review has validated that a resident's toilet was left clogged for 16 hours and 11 minutes (16:11h). Based on LPAs observations, interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, article 05 are being cited. Please see LIC9099-D. There has been one (1) deficiency cited during today's visit. An exit interview was conducted with Dave Hone, executive director (S9) and a copy of this report and appeal rights have been provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 11-AS-20250403121056

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 8, 2025

87303 Maintenance and Operation (a) The facility shall be...in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This has not been met as evidenced by: Based on record review(s), the licensee did not comply with the section cited above as having left a residents' toilet clogged for about 16hrs, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee and LPA have agreed that Canterbury staff will, moving forward, repair any malfunction or non-functioning items throughout the facility and that the executive director (S9) will inform maintenance staff of expectations. S9 will forward this memo to LPA at Mario.Leon@DSS.CA.GOV

Allegation investigated: Staff administered resident a suppository without a prescription

On 04/11/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the above-mentioned facility. LPA was met by staff two, Diana Ernandes Activities Coordinator (S2) and later by staff one, Nicole Prescott Nurse Manager (S1), and the purpose of the visit was explained. LPA was granted entry to the facility. S1 and LPA toured the first floor and basement of the facility. The investigation consisted of the following: On 04/11/25 LPA requested and reviewed facility documents, including the following: Resident roster (dated 04/10/25), staff roster (dated 04/11/25), various facility documentation and all communications between the facility, their contracted Physician and the most updated Dr.'s orders for a resident in care. LPA interviewed five (5) out of one-hundred and thirty-seven (137) residents (R1-R5), eight (8) out of two-hundred and ninety-one (291) staff (S1-S8) and one (1) witness. Report continues, see LIC9099-C Unsubstantiated Investigation revealed the following: Regarding the allegation, "Staff administered resident a suppository without a prescription", it has been alleged that staff have provided a suppository without Dr.'s orders. LPA conducted record reviews of the changes in a resident's primary care physician, listed in order from oldest to newest: Dr. Anna Mellor (AM) from May 2015 (05/15) to March 2021 (03/21), Dr. Christopher Traughber (CT) from 03/21 to March 2025 (03/25), now Dr. Robert Reiss (RR) from 03/25 to current date (04/11/25). LPA reviewed a fax to RR, who ordered, and confirmed, the use of an over-the-counter (OTC) medication following a request from a resident's responsible person(s). RR only confirmed OTC, starting 03/26/25, and did not discontinue (DC) a suppository. LPA further reviewed the medication administration record (MAR) of a resident from the months of February, 2025 (02/25) to April, 2025 (04/25). During the dates in question, there has not been any marked dose of a suppository to a resident in care. On 04/11/25, between 09:00AM and 1:00PM, LPA interviewed eight (8) staff (S1-S8). Between 2:00PM and 4:00PM, LPA interviewed five (5) residents (R1-R5). All eight (8) staff interviewed (S1-S8) and five (5) out of five (5) residents interviewed (R1-R5) have denied the allegation has taken place, while witness one (1) is unsure whether the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. There have been no deficiencies cited during today's visit. An exit interview was held with staff one, Nicole Prescott Nurse Manager (S1), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 11, 2025 · control 11-AS-20250403121056

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 03/28/2025 Licensing Program Manager (LPM) Ulysses Coronel and Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced annual required visit using the CARE Inspection Tool. CCLD staff met with Administrator David Hone and explained the purpose of today’s visit. The facility is licensed to serve a maximum 187 non-ambulatory residents of which 15 may be bedridden. Bedridden only in building E, 2nd floor. Ages 60 and above. Approved hospice for 25 clients. First floor all delayed egress memory care unit. The facility consists of 5 buildings and have a Memory Care Unit, Assisted living, and independent living. The facility is in a residential neighborhood. It has 98 independent living rooms, 18 assisted living rooms, 9 memory care rooms, 28 skilled nursing beds, 12 common bathrooms, 2 laundry areas, Kitchen, kitchenettes & dining area, activity area, lounges, and outdoor shaded patio areas with tables and chairs. CCLD staff and Administrator toured the physical plant. Rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. Bathrooms were operational, . A comfortable temperature was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and 2 days supplies perishable, and 7 days non-perishable food was maintained. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted including Activities Calendar and Food Menu. LPA conducted an audit of 5 resident records, and 5 personnel records. The facility is current in CCLD annual license fees. The administrator certificate for is valid. The facility has a Liability Insurance Certificate valid through 01/01/2026. The following deficiencies were observed during today’s visit : The hot water temperature measured between 122-123 degrees F in rooms E211, E203 and C302. Caregiver S3's Criminal Record Clearance was not transferred to the facility. Title 22, Division 6 Chapter 8 is being cited please see LIC809D. An exit interview conducted, and plans of corrections were developed with Dave Hone. A copy of the report and appeals rights were provided.the state’s words, verbatim · CDSS document, Mar 28, 2025

Type of visit: Case Management - Other

On 02/18/25, Licensing Program Analyst (LPA) Troy Watson made an unannounced visit regarding the relocation of from The MonteCedro Facility# 197610430 to the facility listed above due to mandatory evacuation orders from Fire Advisory. LPA Watson met with Dave Hone and explained the reason of the visit. LPA also spoke with the Director of Residential Health Service Nicole Prescott, and the LVN Care Suites Nurse Manager Lorena Bautista. During the visit, LPA Watson conducted a health and safety check. LPA reviewed medication administration records (MARS) to obtain the names and date of birth from The MonteCedro Facility resident#1-resident # 9 (R1 – R9). Per interview of the Licensee Robin Gordon, nine residents have been relocated to The Canterbury. The facility has sufficient beds, bedding, hygiene supplies and linens. The facility has 141 bedrooms and 195 five bathrooms. The kitchen has sufficient two-day perishables and seven-day non-perishable food supplies. Medications and MARS for the MonteCedro residents have been transferred to the Canterbury and is in the Canterbury computer system and nursing stations. Residents#1-Residents#4 (R1-R4) require incontinence care and are ambulatory with standby assistance, and residents # 5 – residents # 9 (R5-R9) are continent requiring wheelchairs. The Licensee stated each resident uses different vendors, pharmacy, and home health agencies, but the facility can maintain the same level of continued care for the residents. There is sufficient staffing available to provide care for all residents relocated from MonteCedro. It has been verified that a routine fire inspection for the Canterbury was on 02/10/2025 and testing was complete on 02/10/2025 and a fire drill was conducted on 12/21/2024. The licensee confirmed all families, responsible parties, home health, and hospice agencies for The MonteCedro residents have been notified about the relocation either via calls, texts, or emails. An exit interview was conducted with Dave Hone the Executive Director and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 18, 2025

Type of visit: Required - 1 Year

On 4/4/2024, Licensing Program Analysts (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPAs met with Dave Hone / Executive Director. LPAs explained the purpose of today’s visit. The facility is licensed to serve (187) residents ages 60 and above, of which (15) may be bedridden only in building E, 2nd floor. Approved hospice waiver for (25). 1st floor all delayed egress memory care unit approved per code. The facility consists of 5 building and have a Memory Care Unit, Assisted living, and independent living. The facility is in a residential neighborhood. It has 98 independent living rooms, 18 assisted living rooms, 9 memory care rooms, 28 skilled nursing beds, 12 common bathrooms, 2 laundry areas, Kitchen, kitchenettes & dining area, activity area, lounges, and outdoor shaded patio areas with table and chair. LPA toured the physical plant with the administrator. There were no bodies of water or obstructions on the premises. A total of (10) rooms were inspected rooms: 106, 109, 111, A104, A102, A101, A308, A307 and A303. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA reviewed the last date the fire inspection company came to check the smoke detectors. The water temperature was measured adequately between 105F°—and 120 F°. Evaluation Report Continues LIC 809-C During the visit, LPAs Iniguez observed the facility to be clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were observed. Cleaning agents and sharp objects were stored and inaccessible to residents in care. The kitchen was inspected, and sufficient perishable and non-perishable food was correctly maintained. All fire extinguishers were charged and were operable. A review of (7) residents' service files and (7) staff personnel files was conducted. (4) Medication Administration Records (MAR) were reviewed, and no discrepancies were found. The first AID kit was checked. The last fire disaster drill was on 3/19/2024. LPA observed the facility's infection control practices. Liability insurance was provided to LPA. Facility Annual Fess are Current. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Dave Hone /Executive Director.the state’s words, verbatim · CDSS document, Apr 4, 2024