496803880-10-28-2021-21-AS-EGCS-C88Q87-20211028115617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803880
Report Date: 10/28/2021
Date Signed: 10/28/2021 11:56:23 AM

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, THE		FACILITY NUMBER:	496803880
ADMINISTRATOR:	FLETCHER, SOPHIE ANNA		FACILITY TYPE:	740
ADDRESS:	2630 CANTERBURY DRIVE		TELEPHONE:	(707) 578-4309
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	10/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Staff, Regina Borja		TIME COMPLETED:	12:10 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) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 10:20 AM, and met with staff, Regina Borja. Before entering the facility LPA asked COVID risk assessment questions to staff who indicated no one has been sick or exhibited symptoms of COVID within the last two weeks. Administrator, Sophie Fletcher was not present at the time of the visit. Administrator communicated to staff over the telephone to assist LPA with inspection. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of facility with staff and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, infection control and pins are communicated to residents' families by administrator. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. Staff have also been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed licensee has necessary PPE and supplies to support a resident in isolation. LPA requested to see temperature screening logs and determined they were current. Residents' emergency contact information has been updated. Toxins are secured and inaccessible in locked garage. Medications are centrally stored in a locked cabinet making them inaccessible to residents. Exit alarms on exit doors were working properly. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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: 10/28/2021

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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. LPA and staff discussed client activities and visitation. Visitation is encouraged outside but is allowed inside. Visitors are asked to call ahead of time to prevent crowding in the facility. An outside party comes to the facility to put on bingo for the residents every Monday.

Staff showed LPA documentation for last fire inspection on March 17, 2021.

Exit interview conducted with staff and a copy of this report was printed for the administrator.

No deficiencies cited during this inspection

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC809 (FAS) - (06/04)

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