Routine inspection·November 4, 2025

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)