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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803425
Report Date: 02/09/2023
Date Signed: 02/09/2023 12:20:26 PM

Document Has Been Signed on 02/09/2023 12:20 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
SANTA ROSA RO, 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:
02/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Administrator, Heather DeghiTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Victoria Bertozzi 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 showed LPA their visitor sign in book and confirmed that visitors are being screened. LPA initiated a walk-through of the facility around 11:20am and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected twice per day, per Administrator.

Facility has a designated visitation area outside and is allowing for visitation inside per CCL guidance. Staff continue to receive training on infection control and Personal Protective Equipment (PPE). Staff have been N95 fit tested. Administrator and LPA discussed visitation and activities.

Facility has more than a 30 day supply of PPE including but not limited to masks, gloves, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguishers were last serviced March 2022. Facility has a new fire system that was installed December 2022 and will be maintained by a vendor. Carbon monoxide detector was tested and operational.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: COUNTRY GARDENS CARE HOME
FACILITY NUMBER: 496803425
VISIT DATE: 02/09/2023
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Continued from LIC809

Facility has submitted their Infection Control Plan and Mitigation Plan.

Administrator to submit updates of the following documents by 03/09/2023:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
Updated Mitigation Plan (if changes)
Updated Infection Control Plan (if changes)

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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