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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801354
Report Date: 03/12/2024
Date Signed: 03/12/2024 04:29:25 PM

Document Has Been Signed on 03/12/2024 04:29 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: 5DATE:
03/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Cecelia Demonteverde, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection to the above-named facility. Upon arrival, there were five (5) residents in care, 1 staff on duty with the Administrator also on duty.. 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 ambulatory and non-ambulatory residents with a dementia diagnosis. There are currently three residents on hospice.
Entrance interview conducted:
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.
LPA toured the facility with Administrator. LPA observed four (4) resident bedrooms. Two of the resident rooms are shared and two are private. Bedrooms 1 and 4 have private bathrooms. There is a bathroom off the hallway near bedrooms 2 and 3. All residents have accessibility to the hallway bathroom. There are two staff bedrooms that are inaccessible to residents in care.

Walls, floors, and doorways are clean with no safety hazards. The kitchen area consists of a countertop area, a refrigerator, a stove, a microwave, and a sink. Sharps and centrally stored medications are kept in a locked cabinet under the kitchen sink. Fire inspection was current as of 7/5/2023.

There is a sufficient amount of perishables for seven (7) days and non-perishables for two (2) days. Emergency food is stored in a second refrigerator and pantry located in the garage. There is a washing machine and a clothes dryer in the garage. Chemicals and toxic substances are kept in a locked cabinet under the kitchen sink.

Please continue to 809-C, Pg 2.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2024
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: 03/12/2024
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 The facility has eight dual smoke alarm/carbon monoxide detectors and a pull fire alarm that alerts the local fire department. The living room and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors and walls are in good repair.
Residents may participate at will in activities such as personal care appointments, medical appointments, games, exercising, neighborhood walks, and sitting on the patio.
The backyard consists of paved walkways,potted plants, and sitting areas with tables and chairs. The recycling bin, green waste bin, and trash bins are standard bins with flip lids.

Exit interview conducted. Technical advisories were noted. Copy of report issued at the time of the visit.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024
LIC809 (FAS) - (06/04)
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