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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801354
Report Date: 04/02/2025
Date Signed: 04/02/2025 03:34:17 PM

Document Has Been Signed on 04/02/2025 03:34 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/
DIRECTOR:		CECILIA/NESTOR DEMONTEVERDFACILITY TYPE:
740
ADDRESS:778 RIBERA DRIVETELEPHONE:
(805) 692-5083
CITY:SANTA BARBARASTATE: CAZIP CODE:
93111
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Cecilia Demonteverde, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 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 six (6) residents in care, 2 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 five 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 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 2/11/2025.
There is a sufficient amount of non-perishables for seven (7) days and 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.

Kelly BurleyTELEPHONE: (805) 562-0413
Kristin KontilisTELEPHONE: (805) 689-2787
DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/02/2025
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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. Upon arrival, LPA observed family members of three different residents at the facility. Administrator Demonteverde stated family members visit daily and participate with residents in various activities including special celebrations.
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. No deficiencies noted. Copy of report issued at the time of the visit.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin KontilisTELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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