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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800794
Report Date: 07/13/2023
Date Signed: 07/13/2023 11:48:49 AM

Document Has Been Signed on 07/13/2023 11:48 AM - 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:SUNSET HOUSEFACILITY NUMBER:
496800794
ADMINISTRATOR:CATTICH, DOUGLASFACILITY TYPE:
740
ADDRESS:9408 WILLOW AVETELEPHONE:
(707) 795-7882
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY: 9CENSUS: 9DATE:
07/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Douglas Cattich, Licensee/AdministratorTIME COMPLETED:
12:00 PM
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License Program Analyst's (LPA) Shannan Hansen arrived at 10:30 AM to complete an unannounced annual inspection and met with Douglas Cattich, Licensee/Administrator. There is a total of 9 residents.

LPA reviewed centrally stored medication record, and finished tour of facility to complete this annual inspection

The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 7/13/2023 at 10:55 AM. However, residents medications have been 24 hour pre-poured and new regulation 87465(h)(5) states No medications shall be transferred between containers. (see LIC 9102 Advisory Notes) Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.


LPA reviewed Licensing Information System (LIS) Licensee/Administrator Doug Cattich who stated that is corrected and updated at this time; no need to change any of the information. In addition. Disaster Drills have been conducted quarterly with the last one being conducted on 4/4/2023.
There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 7/31/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

LIC 9020 Residents Roster

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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