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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803880
Report Date: 08/03/2020
Date Signed: 08/03/2020 03:34:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CANTERBURY HOME, THEFACILITY NUMBER:
496803880
ADMINISTRATOR:FLETCHER, SOPHIE ANNAFACILITY TYPE:
740
ADDRESS:2630 CANTERBURY DRIVETELEPHONE:
(707) 578-4309
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 5DATE:
08/03/2020
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sophie Fletcher, LicenseeTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Most conducted a tele-visit inspection on 8/3/2020 at approximately 9:00 AM to conduct a post licensing visit. LPA is conducting a tele-visit with Administrator/Licensee Sophie Fletcher. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. Currently there are 5 residents in care..

The amount of fresh and nonperishable foods appeared to be within regulation. LPA observed additional foods stored in the garage. Sharps and medications appeared to be in locked cabinets in the kitchen. A medication refrigerator was observed in the locked garage. Food is available for residents any time of the day with a menu board posted in the kitchen. Toxins were observed locked in the laundry room and in the locked garage. Bathrooms were equipped with necessary grab bars and non-slip floors/mats and appeared to have sufficient hygiene products. Fire extinguishers inspected were charged and dated 7/3/2020 per Licensee. LPA observed required postings regarding COVID-19 precautions throughout the facility and required visitation postings. Facility is screening essential visitors at the front door which includes taking temperatures and completing a questionnaire regarding symptoms.

Facility utilizes a pendant system for residents with the base in a central location.

LPA observed a sufficient supply of PPE including gloves, gowns and face shields.
Licensee provides activities such as one on one walks, puzzles, etc. with residents.

LPA did not review resident files as current shelter in place only allows for essential medical visits at this time. Licensee states there are no residents admitted with prohibited conditions and that 1/2 rail orders are on file for those with the postural supports. Licensee furthers states that all needs/service plans and appraisals are up to date.
Continued on 809-C
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley MotaTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CANTERBURY HOME, THE
FACILITY NUMBER: 496803880
VISIT DATE: 08/03/2020
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LPA reviewed 2 staff records and found that staff had current 1st aid / CPR and training.

Licensee stated disaster drills are conducted quarterly.
Sophie Fletcher Administrator Certificate 6052189740 expires 5/19/2021.


No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley MotaTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2020
LIC809 (FAS) - (06/04)
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