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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803760
Report Date: 02/18/2022
Date Signed: 02/18/2022 02:30:47 PM

Document Has Been Signed on 02/18/2022 02:30 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 GARDEN IIFACILITY NUMBER:
496803760
ADMINISTRATOR:CHERNIZER, OFELIAFACILITY TYPE:
740
ADDRESS:320 KIVA PLACETELEPHONE:
(707) 548-5753
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Eden Relota-Licensee/AdministratorTIME COMPLETED:
02:40 PM
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Licensing Program Analyst(LPA) Alviso arrived unannounced to conduct a Required 1 Year inspection and met with Licensee/Administrator Eden Relota. The inspection is focused on the Infection Control procedures and practices of this facility. LPA reviewed infection control procedures with Eden, the Administrator.

LPA was screened for covid symptoms, including temperature being taken, at the front entrance as the LPA stepped inside of the facility.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Mitigation plan was reviewed by the Department. Fire clearance is approved for four (4) non-ambulatory, of which one(1) may be bedridden.
There were four (4) residents in care at the facility, and two(2) of them are receiving hospice care. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. Medications were locked in a cabinet making them inaccessible to residents in care. All bathroom(s) had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator and two staff on duty had masks on during the LPA's inspection.
No deficiencies cited today.
Exit interview conducted with the Licensee/Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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