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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801554
Report Date: 06/27/2022
Date Signed: 06/27/2022 02:32:04 PM

Document Has Been Signed on 06/27/2022 02:32 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
06/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Eden Relota (Licensee)TIME COMPLETED:
02:46 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Eden Relota, Licensee/Administrator. The purpose of this case management inspection is to follow up on a self reported incident report dated 6/21/22 received from Licensee on 6/23/2022 informing Community Care Licensing (CCL) of an observation of a died bed bug on resident's (R1 and R2) shared bedroom. LPA made observations and conduct interviews with Licensee.

LPA was informed Ecolab Pest Control came to conduct a chemical treatment of all resident's rooms including R1 and R2 shared room where observation of bed bug were made. LPA was informed residents have been checked and do not have any bites. Per Ecolab's recommendation all bedding and clothing were laundered after treatment and new sheets had been placed on R1 and R2's mattresses. During this treatment the residents were relocated to another place for one day. LPA was informed that pest control will come back within a week to ensure that the facility doesn't need a second treatment for bed bugs in resident(s) rooms. LPA was informed all clothing/bedding items being brought into the facility for R1 and R2 where launder immediately and room checks will continue. During today's visit LPA requested that facility provide follow up documentation that the pest control company finds that there is no evidence of bed bugs to CCL upon completion and plan to continue room checks. LPA was provided a copy of facility Emergency Disaster Plan (LIC610E) dated 5/2/22 that it does not address a current plan including resident's place to be relocated in case of an incident of bed bugs. Licensee updated Emergency Disaster Plan (LIC610E) and re-submitted to CCL for review.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2022
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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