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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803760
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:32:46 PM

Document Has Been Signed on 12/22/2022 01:32 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 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:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Eden Relota-AdministratorTIME COMPLETED:
01:40 PM
NARRATIVE
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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. There were two other caregivers, Robert White and Henedina(Heidi) Jumalon , on duty during the inspection. The inspection is focused on the Infection Control procedures and practices of this facility.

Administrator submitted to the Department, as required, the facility's Infection Control Plan. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. 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.

Staff screened LPA for covid symptoms, including temperature being taken; Staff logged the screening information. LPA reviewed resident and staff files.
Two residents are receiving hospice services. All staff have criminal record clearance as required. S4 lacked current first aid certification, deficiency will be cited, 87411(c)(1) Personnel Requirements -General, see LIC809D.

Facility was found to be clean, and at a comfortable temperature with all exits free from obstruction. Carbon monoxide detector was working when checked during the inspection. All smoke alarms were working when checked during the inspection. 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). Sufficient food supply.

Continued on LIC809C....
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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Document Has Been Signed on 12/22/2022 01:32 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/22/2022 at 11:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSET GARDEN II
FACILITY NUMBER: 496803760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2022
Section Cited

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Personnel Requirements-General 87411(c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 . Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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This requirement was not met as evidenced by: LPA reviewed staff files, S4 lacked required first aid training/certification. S4's first aid certification expired 8/1/2020. This is a potential risk to of personal rights and/or health and safety to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


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 II
FACILITY NUMBER: 496803760
VISIT DATE: 12/22/2022
NARRATIVE
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LPA observed the fire extinguisher was not serviced and tagged as required-expired 11/18/2022,, and LPA observed the garage to have an area set up as a staff sleeping/living area, with staff's personal belongings in this area, deficiencies were cited, Fire Safety 87203, see LIC809D.

LPA discussed Fire Safety regulations with the Licensee, who stated their understanding to the LPA. The Licensee stated that she will submit plan of correction on all deficiencies cited.

The following deficiency(s) was/were cited from California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with the Administrator. Appeal Rights provided to the Licensee/Administrator.

LPA requested Licensee to update the following documents by 1/9/2023.

LIC 308 Designated
LIC 500 Personnel Summary-all staff names/titles-days/hours working
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s.
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/22/2022 01:32 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/22/2022 at 12:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSET GARDEN II
FACILITY NUMBER: 496803760

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review and observation, fire extinguisher tag expired 11/18/2022, the licensee did not comply with the section cited above in [1] out of [1] fire extinguisher which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the garage to have a couch, tv, personal belongings of S3-clothes, mail, shoes, stored personal food , and other personal miscellaneous items. The garage is not fire cleared for a sleeping area/room.which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2022
Plan of Correction
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Licensee to ensure that the fire extinguisher(s) is serviced and tagged annually as required; Submit proof of fire exinguisher having been serviced and tagged no later than 12/23/22. Licensee to ensure that the garage is cleared from a staff living/sleeping area and submit plan of correction, and submit pictures of the garage being cleared of sleeping/living area, by 12/23/22. This is a fire code violation as discussed with Licensee today, and in the past.LPA obtained pictures. POC due 12/23/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


LIC809 (FAS) - (06/04)
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