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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803425
Report Date: 02/08/2022
Date Signed: 02/08/2022 01:19:10 PM

Document Has Been Signed on 02/08/2022 01:19 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:COUNTRY GARDENS CARE HOMEFACILITY NUMBER:
496803425
ADMINISTRATOR:DEGHI, HEATHERFACILITY TYPE:
735
ADDRESS:2680 WOOLSEY ROADTELEPHONE:
(707) 546-5894
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 10CENSUS: 9DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Heather DeghiTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced, to conduct an Annual Required inspection and met with Administrator, Heather Deghi. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, Administrator checked LPA temperature and asked standard Covid-19 screening questions. Facility is having visitors sign in. LPA conducted a walk-through of the facility and observed Covid-19 posters throughout the facility. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas and in client rooms. Facility has hand washing supplies in bathrooms and kitchen. Per Administrator, they regularly discuss infection control with clients and staff. Clients are encouraged to wear masks when in the community and staff are required to wear them while in the facility. Observed staff had a mask on during this visit. Facility checks staff temperatures at the beginning of their shift and client temperatures daily and documents results. Facility is currently following vaccination verification for visitors per CCL guidance. Commonly touched surfaces are disinfected twice per day. Staff have received training on proper use of PPE and have been N-95 fit tested. LPA and Administrator discussed client activities and visitation.

Fire extinguishers were last serviced March 2021. Facility has a fire system that is monitored and serviced by a vendor. System has been serviced within the last year. Facility has submitted and CCL has received their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, N-95s, gloves and hand sanitizer. LPA suggested that facility acquire some gowns in case a client must go into isolation. PPE is located where it is accessible to staff who need it. Facility maintains a 30 day supply of medication.

LPA confirmed that facility is signed up to receive Provider Information Notices and is aware of the most recent Covid-19 guidance from CCL.

Administrator and LPA discussed their Emergency Disaster Plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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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