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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801554
Report Date: 10/01/2021
Date Signed: 10/01/2021 11:46:32 AM

Document Has Been Signed on 10/01/2021 11:46 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SUNSET GARDENFACILITY NUMBER:
496801554
ADMINISTRATOR:RELOTA, MECHELLEFACILITY TYPE:
740
ADDRESS:1018 SUNSET AVE.TELEPHONE:
(707) 528-8512
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 6DATE:
10/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Eden Relota (Licensee)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection and a case management to this facility. During today's visit LPA met with Licensee, Eden Relota. LPA conducted a Risk Assessment call with staff prior to the visit.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept in the common area of the facility but not throughout due to safety concerns. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility has designated an outdoor area for visitation. Facility has a designated isolation apartment on the facility premises for residents that need to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols but not all staff have been N-95 fit tested. Staff and residents are being monitored daily and results are documented in a binder for each month. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Activities had been reduced to more outdoor areas to prevent the spread of the virus. Residents have access to alternative communications as phone calls and video calls with their families.

Facility has submitted their Covid Mitigation Plan and approved on 1/19/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. PPE supplies are located in an accessible place for all staff and more supplies are kept in the garage.

Continues on LIC809C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2021
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SUNSET GARDEN
FACILITY NUMBER: 496801554
VISIT DATE: 10/01/2021
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During today's visit, LPA followed up on an incident report received on 9/20/21 regarding resident (R1) who on 9/15/21 around 11am complained to staff that they were having severe stomach pain. Staff contacted 911 immediately and R1 was transported to Kaiser Hospital for further evaluation. Responsible parties were notified. R1 was diagnosed with apendics and scheduled for surgery on 10/6/21.

Licensee agreed to submit the following documents by 10/8/21: Designation of Responsibility (LIC308), Liability Insurance and Personnel Report (LIC500).

No deficiencies observed during today's visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021
LIC809 (FAS) - (06/04)
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