The Canterbury Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Co-administrator Donald Fletcher (CA) arrived later and was available by phone. LPA also spoke to licensee Sophie Fletcher via Facetime. Facility currently has six (6) residents, four (4) of which are currently on hospice. While CA was at the facility LPA discussed with CA the front ramp hand rail in middle section on the right hand side. Rail is slightly loose and separated from the next following piece of rail. Rail does not present as a hazard, but could present as a potential issue in the future should it become looser. CA will fix rail piece. Administrator is Sophie Fletcher Administrator Certificate 7019221740 expires 5/19/27. Co-administrator is Donald Fletcher Administrator Certificate 7022153740 expires 10/4/26. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed kitchen cabinet under sink to contain disinfectants and cleaning supplies. Cabinet has magnetic locking mechanism. All other cleaning products and laundry soaps are secured and inaccessible to residents in care. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 107.8 degrees F in the main bath, 107.1 degrees F in the kitchen and 108.1 degrees F in the back bathroom all of which are within the allowable range of 105 to 120 degrees F. Facility has a small half bath used by staff only. Continued on 809C... Continued from 809... Fire extinguishers were last inspected 06/27/25. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted on 07/28/25. LPA discussed with caregiver conducting the disaster drills quarterly. At approximately 1:00pm LPA conducted a review six (6) staff records. LPA observed licensee to perform Health Screen for S1, S2, S3, and S4. Licensee is a practicing doctor. LPA discussed with licensee performing her own Health Screens and that it could present as a conflict of interest to perform them on her own employees. LPA observed first aid certifications for all staff to be issued by American Academy of CPR & First Aid, Inc. However, this company is not affiliated with the American Red Cross as suggested by regulation 87411(c). LPA advised caregiver. Licensee conducts medication training for all staff. LPA observed training records for S1 and S2 to include medication training but LPA could not locate medication test required of those administering medication to residents as required by Health and Safety Code 1569.69(a)(5). Additionally, three (3) of six (6) staff did not have current training records present at facility. LPA discussed with licensee and she provided copies of training records via Facetime. No deficiencies cited. At approximately 2:00pm LPA conducted a review of six (6) out of six (6) resident files. No deficiencies cited. Licensee currently has residents with bedridden status; however, they are both on hospice. LPA advised licensee should they graduate off hospice she will need to notify the fire department and notify CCL. Once notification occurs, LPA can best advise how to proceed. At approximately 3:00pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA performed thorough medication management review with caregiver, discussing current physician's orders, PRNs, PRN MAR, MARs, and Centrally Stored Medication Log. No deficiencies cited. No deficiencies cited during this inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance (expires in December of 2025)the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Sophie Fletcher was contacted by phone and gave caregiver permission to sign. Facility contact information was reviewed. At approximately 1:30pm LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Laundry room off of kitchen contains cleaning supplies in locked cabinet. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 108.1 and 109.3 degrees F which is within the allowable range of 105 to 120 degrees F. Facility has hardwood flooring in kitchen, some planks/tiles were loose and adhesive needs to be reapplied. Per LPA discussion with licensee, facility has contractor that will be fixing loose planks/tiles. Licensee advised LPA that repairs will be completed within two weeks. Fire extinguishers were last inspected 9/9/24. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted on 11/2024. At approximately 2:30pm LPA conducted a review of 6 resident records. All required documentation present. 1/2 rails or faxed request for half rails were on file for respective residents. Continued on 809C... Continued from 809... At approximately 3:45pm LPA conducted review of 5 staff records. All required documentation present. At approximately 4:30pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Sophie Fletcher Administrator Certificate 7019221740 expires 5/19/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Liability Insurance No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Dec 10, 2024

The state marks this report as 3 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

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Donalisa Davis, Caregiver. Keith (Donald Keith) Fletcher, Licensee arrived later at approximately 9:30am. Regina Borja, Administrator (certificate# 6066761740 expires 8/6/2025) arrived later at approximately 9:45am. Sophie Fletcher, Administrator arrived at approximately 12:00pm. Facility currently has five (5) residents, two (2) of which are on hospice which is allowable per the facility's Hospice Waiver for three (3). Facility contact information was reviewed. At approximately 9:45am LPA, and Administrator Borja toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. 4 cans of sweet yams were expired as of 9/2023. LPA observed Administrator immediately discarding expired cans in trash (see Technical Violation). Kitchen cabinet containing cleaning supplies was locked. LPA observed fireplace in dining area that needs to be screened. Administrator says it is not in use (see Technical Violation). All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 105.3 and 112.8 degrees F, respectively, which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected July 14,2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 10/30/2023. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... LPA and Administrator Borja observed extension cord delivering electricity to refrigerator in recently remodeled storage building in backyard. Per LPA interview with Administrator Fletcher LPA was provided a Santa Rosa Fire Department (SRFD) report of a fire inspection conducted 3/31/2023 and a subsequent inspection 04/18/2023. LPA subsequently spoke to Fire Dept Inspector that conducted the aforementioned inspections via telephone. Per LPA conversation with Fire Inspector Aivars Meiers (inspector # 8481) the Accessory Dwelling Unit (ADU) in the back (at address 2241 Yucca St, Santa Rosa,CA) was not completely finished when he completed his inspections. Inspector Meiers indicated he did not observe any extension cords delivering electricity to the refrigerator in back unit at the time of his inspection. Administrator Borja confirmed refrigerator in back unit not operable and was not receiving electricity via extension cord until mid September 2023. Inspector advised LPA the extension cord is a violation and must be removed immediately. Inspector advised LPA that he will now be conducting an inspection next week (week beginning 12/4/2023) and he will notify both CCL and City of Santa Rosa Code Enforcement of his findings. Once CCL receives the new inspection report, LPA will review and may contact licensee. Per Title 22 regulation 87202(a)Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal (deficiency cited see 809D) At approximately 12:00pm LPA conducted a review of 5 out of 5 resident records. LIC602 for resident (R1) with diagnosis of dementia not current within 12 months. Per Title 22 regulation 87705(c)(5)(A): Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident (deficiency cited see 809D) Continued on 809C... Continued from 809C... At approximately 2:00pm LPA conducted a review of 5 out of 10 staff records. All required documents present including current training. At approximately 3:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the dining room/office area. Sophie Fletcher Administrator Certificate 6052189740 expired 5/19/2025. All fees are current as of this time. LPA and Administrator Fletcher discussed facility's Infection Control Plan and Emergency Disaster Plan. Administrator will send copy of Infection Control Plan and Emergency Disaster Plan if any updates to CCL within 30 days. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC308- Designation of Responsibility Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, Nov 30, 2023

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.