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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803880
Report Date: 11/30/2023
Date Signed: 12/01/2023 08:43:06 AM


Document Has Been Signed on 12/01/2023 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Regina Borja, AdminsitratorTIME COMPLETED:
05:10 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) 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...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
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 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CANTERBURY HOME, THE
FACILITY NUMBER: 496803880
VISIT DATE: 11/30/2023
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
26
27
28
29
30
31
32
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...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CANTERBURY HOME, THE
FACILITY NUMBER: 496803880
VISIT DATE: 11/30/2023
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
26
27
28
29
30
31
32
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 given

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/01/2023 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CANTERBURY HOME, THE
FACILITY NUMBER: 496803880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and interview with Santa Rosa Fire Department (SRFD) Inspector Aivars Meiers, the licensee did not comply with the section cited above by running an extension cord delivering electricity from the main house to unit in back (at address 2241 Yucca St, Santa Rosa,CA) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
1
2
3
4
Administrator to provide photos of extension cord unplugged and removed, no longer delivering electricity to refrigerator. Administrator to provide photos of emptied refrigerator as well.
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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 12/01/2023 08:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: CANTERBURY HOME, THE
FACILITY NUMBER: 496803880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [1] resident records (R1) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
1
2
3
4
Administrator to fax updated LIC602 for R1 once received from doctor.
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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 5 of 7