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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803425
Report Date: 02/13/2025
Date Signed: 02/13/2025 03:04:25 PM

Document Has Been Signed on 02/13/2025 03:04 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/
DIRECTOR:		DEGHI, HEATHERFACILITY TYPE:
735
ADDRESS:2680 WOOLSEY ROADTELEPHONE:
(707) 546-5894
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 10CENSUS: 9DATE:
02/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Heather Deghi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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At approximately 09:45 AM, Licensing Program Analysts (LPAs) Robert Frank and Star Stevenson arrived unannounced to conduct a 1-Year Required Visit and met with Administrator, Heather Deghi. Country Gardens Care Home is licensed as an Adult Residential Care Facility. The facility is a one (1) story ranch style house with six (6) client bedrooms, two bathrooms, and common spaces. The facility has an approved fire clearance and capacity for ten (10) ambulatory clients. LPAs were informed that two (2) staff members were present. At approximately 10:00 AM, LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation with the exception of one (1) staff member (S1) who was cleared in Guardian but not associated with the facility. This deficiency will be cited.

At approximately 10:30 AM LPAs conducted a walk-though of the facility with Administrator Deghi. The facility was observed to be clean and at a comfortable temperature with all exits free from obstruction. The facility had emergency lighting and has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for clients. Mattress pads were in place or available for client use. Toxins were observed to be stored inaccessible to clients. Bathrooms were observed to have non-slip floors mats. One (1) shower ceiling light cover was observed to be missing. A technical violation is being issued for not having the ceiling light cover. Hot water temperatures for 3 sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.

Fire extinguishers were last inspected 1/2025. Carbon monoxide detectors were tested and operational. Facility has a hard-wired alarm system for smoke and fire that was last inspected in 11/2024. Disaster drills are conducted quarterly. The last facility fire/disaster drill was conducted on 09/18/2024.

Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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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: 02/13/2025
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...Continued from 809

At approximately 11:15 AM, LPAs reviewed five (5) client files. Five (5) of five (5) client files were observed to have all required documentation. LPAs reviewed five (5) staff files. Five (5) of five (5) staff files had all required documents, First Aid certification and proper training documentation. LPAs spot checked Medication for three (3) clients. Medication was observed to be centrally stored and secure with proper documentation. Personal and Incidental (P&I) monies were documented, secure and not commingled.

Administrator's Certificate for Heather Deghi (7005899735) was current with an expiration date of 08/22/2026.

LPA requested the following documents be submitted to Community Care Licensing by 3/13/2025:



LIC 308 Designation of Facility Responsibility
LIC 610D Emergency Disaster Plan
LIC 500 Updated Personnel Report
LIC 402 Surety Bond – Updated to reflect Higher Value per Title 22 Regulations
LIC 9020 Register of Clients/Residents

Exit interview conducted. Copy of report, LIC809D (Deficiency Page) with plans of corrections, LIC9102 Technical Violation, Confidential Names (LIC811), and Appeal Rights discussed and provided to Administrator Deghi. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/13/2025 03:04 PM - It Cannot Be Edited


Created By: Robert Frank On 02/13/2025 at 02:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: COUNTRY GARDENS CARE HOME
FACILITY NUMBER: 496803425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above that staff member (S1) was cleared in Guardian but not associated with the facility. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee or Administrator will submit to Community Care Licensing (CCL) proof that staff member S1 has been asscociated to the facility in the Guardian System or send an LIC 9182 Criminal Record Exemption Request to CCL by POC Due Date of 2/17/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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