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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801354
Report Date: 04/27/2022
Date Signed: 04/27/2022 05:03:42 PM

Document Has Been Signed on 04/27/2022 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:COUNTRY GARDEN'S HOME CARE FOR THE ELDERLYFACILITY NUMBER:
425801354
ADMINISTRATOR:CECILIA/NESTOR DEMONTEVERDFACILITY TYPE:
740
ADDRESS:778 RIBERA DRIVETELEPHONE:
(805) 692-5083
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6CENSUS: 6DATE:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Cecilia Demonteverde, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA began the inspection at 10:20 AM. A Mitigation Plan has been submitted to CCLD. LPA was greeted by Administrator, Cecilia Demonteverde and explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. There are currently four residents on hospice.
Entrance interview conducted:
At the time of the arrival, there were 4 staff on duty and 6 residents in care. LPA met with Licensee Cecilia Demonteverde throughout the inspection.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed a fire extinguisher mounted to the left of the front door entering the facility was serviced on 4/30/2020. LPA observed a fire extinguisher in an unopened box on the floor below the mounted fire extinguisher. During the visit, Administrator Nestor Demonteverde took the expired fire extinguisher and the extinguisher in the unopened box to Nargan Fire & Safety Co, Inc, for fire safety inspection. Per Administrator, the expired fire extinguisher was 6 years old and too old for inspection clearance; the fire extinguisher in the unopened box is a disposable one-time use extinguisher and could not be serviced. Administrator Nestor Demonteverde purchased a new 5 lb extinguisher. LPA observed Administrator obtain a package of two carbon monoxide detectors from the kitchen pantry closet. Administrator stated the carbon monoxide detector located in the hallway was damaged and was knocked off the wall from the residents' wheelchairs. During the inspection at 11:20 am, LPA observed Staff 1 (S1) installed one detector in the kitchen area and one detector
Please continue to 809-C.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COUNTRY GARDEN'S HOME CARE FOR THE ELDERLY
FACILITY NUMBER: 425801354
VISIT DATE: 04/27/2022
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in the residents’ hallway. There are ten hard-wired smoke alarms throughout the facility. The smoke alarms will alert the local fire department when activated.
The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. Snacks and beverages are available for Residents in the facility throughout the day and evening. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. The kitchen trash is kept in a receptacle with a foot pedal. Cleaning agents and sharps are kept in a locked cabinet under the kitchen sink. Medications are kept in a locked centrally stored cabinet.
The backyard has a covered patio with outdoor furniture, and a shed. At approximately 11:09 am, LPA observed a bucket containing 5 bottles of toxic chemical agents including but not limited to Turtle Wax Seal & Shine, window cleaner, leather cleaner, and carpet cleaner. The container was located next to an unlocked storage shed. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.
The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 77 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair.
The facility has four (4) bedrooms for a capacity of six residents. Bedrooms #1 and #2 are shared bedrooms with a private bath. Bedrooms #3 and #4 are private bedrooms for one (1) resident each. Residents in Bedrooms 3 and 4 share Bathroom #2. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting. The bathrooms have secure grab bars.
There are two private bedrooms for Licensees, Licensees’ family, and staff located behind the kitchen and laundry area. The private staff bedroom area is locked and inaccessible to residents in care.
A criminal background fingerprint clearance has been completed for all staff members.

Exit interview conducted. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Today’s report and Appeals Rights were reviewed and emailed to Administrator Cecilia Demonteverde.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/27/2022 05:03 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 04/27/2022 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COUNTRY GARDEN'S HOME CARE FOR THE ELDERLY
FACILITY NUMBER: 425801354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as the fire extinguisher was last serviced 4/30/2020 and due to being six years old, could not pass fire safety inspection which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/27/2022
Plan of Correction
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Upon observation, Administrator Nestor Demonteverde purchased a new fire extinguisher. The new fire extinguisher was installed on this day. Administrator agrees to stay current on fire extinguisher safety inspections. POC cleared this date.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) …toxic substances such as …cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as a container with toxic agents of window cleaner, leather cleaner, carpet cleaner, and seal and shine car wax located in the backyard area next to an unlocked storage shed was observed by LPA which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/27/2022
Plan of Correction
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Administrator agrees to keep toxic agents inside the locked storage unit. Administrator removed container and locked storage shed during LPA’s visit. POC cleared this date.
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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/27/2022 05:03 PM - It Cannot Be Edited


Created By: Kristin Kontilis On 04/27/2022 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COUNTRY GARDEN'S HOME CARE FOR THE ELDERLY
FACILITY NUMBER: 425801354

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.311

§1569.311 Carbon monoxide detectors required; inspection: Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, no carbon monoxide detectors were installed in the facility which poses an immediate health and safety risk to residents in care.
POC Due Date: 04/27/2022
Plan of Correction
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Administrator agrees to install carbon monoxide detectors in the residents’ hallway and kitchen of the facility. Staff 1 (S1) installed two carbon monoxide detectors during LPA's visit. POC cleared this date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022


LIC809 (FAS) - (06/04)
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