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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801354
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:42:53 AM

Document Has Been Signed on 02/27/2023 11:42 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
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: 5DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:03 AM
MET WITH:Cecila Demonteverde / LicenseeTIME COMPLETED:
12:15 PM
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 At 10:00am on 02/27/203, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the annual, infection control inspection. LPA met with Licensee, Cecila Demonteverde, announced who he was and the reason for the visit. Licensee and LPA reviewed facility staff roster to confirm current staff clearance to work at the facility.
Licensee and LPA conducted a cursory tour of the facility. This is a six bedroom, four and a half bathroom home with covered back porch, living room, dining room, and kitchen. Two of the bedrooms are single occupancy resident bedrooms and two bedroom is a double occupancy resident bedroom, one bedroom is designated as a staff bedroom. There are 4.5 bathrooms and three bathrooms are designated for residents and one bathroom is designated for staff as an on suite bathroom. The half bathroom is considered a all facility bathroom. LPA observed all bedrooms to be in compliance with regulation standards. LPA noted that there is a large back yard and side yard with a larger pergola and orange tree for shade. LPA observed at least two days of perishable and at least seven days of non-perishable foods on hand at the facility. LPA observed liquid soap and paper towels in each bathroom. LPA observed at least a 30 day supply of PPE located in the dining-room closet. LPA observed fire detector carbon monoxide combination units in all the rooms throughout the facility to be working. This facility has an internal sprinkler system that was serviced by Payless Water Heater and AC on 12/27/2022 . LPA noted that the facility was clean and in good repair and all exits were free and clear of obstructions. LPA noted that no violations, technical, or citations were issued as a result of the cursory walk through tour of the facility at this time .
LPA and Licensee conducted the infection control module of the annual inspection. LPA noted that there were no violations, technical, or citations issued as a result of the annual infection control module. LPA noted that this annual had no violations, technical, or citations issued at this time.

Exit interview, report singed, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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