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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801554
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:18:24 PM

Document Has Been Signed on 12/13/2022 03:18 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: 4DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Licensee Eden RelotaTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection at this facility. During today's visit LPA met with Licensee, Eden Relota. There are 4 residents at facility.

LPA initiated a tour of the facility at 1:35 pm and observed the following: Facility was a comfortable temperature and pathways were free from obstructions. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Hot water temperature in resident's bathrooms measured at 110.4 degrees F. and 116.4 degrees F which is within allowable range of 105 to 120 degrees F. Medications were centrally stored and locked in the living room next to the office at time of inspection. Toxins are located in a locked cabinet in the garage. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last serviced 12/05/2022. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. There is a pull fire alert in the front hallway. Exit doors have auditory alert system that were functional at time of visit. Last Disaster Drill was conducted on 12/01/2022.

Infection Control:


Facility has submitted a mitigation program plan and infection control plan. Posters have been placed at facility and entrance has hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in front room & garage.

In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNSET GARDEN
FACILITY NUMBER: 496801554
VISIT DATE: 12/13/2022
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LPA Hansen reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1st Aid certification for staff.


Administrator Certificate is for Michelle Relota 6014149740 Exp. 5/21/2024
All staff & residents have received COVID booster vaccinations.

There were no deficiencies cited at this time

Licensee provided all required updated documents to LPA at today’s annual inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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