Facility Evaluation Report

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.