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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803760
Report Date: 03/03/2025
Date Signed: 03/03/2025 04:29:33 PM

Document Has Been Signed on 03/03/2025 04:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SUNSET GARDEN IIFACILITY NUMBER:
496803760
ADMINISTRATOR/
DIRECTOR:		RELOTA, EDENFACILITY TYPE:
740
ADDRESS:320 KIVA PLACETELEPHONE:
(707) 548-5753
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 4CENSUS: 4DATE:
03/03/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:25 PM
MET WITH:Eden Relota-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alviso and Contreras conducted a continued annual inspection, on 3/3/25 at approximately 2:25pm, and met with Administrator Eden
Relota. There are four clients in care.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. The facility has a required infection control plan. The facility has a required emergency and disaster plan. Licensee is completing fire/evacuation/emergency drills quarterly as required.

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. Two (2) fire extinguishers were serviced and tagged as required. All exits were clear and free of obstructions. All exits had auditory alarms on the doors; All alarms were working properly during the inspection. Facility has a carbon monoxide detector that was working properly during the inspection.

LPA reviewed four (4) resident files, including medication storage and medication records.

LPAs reviewed four (4) staff files. All staff have required, criminal record clearance, first aid certification, and CPR certification

LPA is requesting the following documents be updated and submitted by 4/03/25.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Continued on LIC809C....
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNSET GARDEN II
FACILITY NUMBER: 496803760
VISIT DATE: 03/03/2025
NARRATIVE
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Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiencies were observed:

Per LPA's file reviews staff, 2, 3, and 4 lacked required medication training. This deficiency will be cited, HSC 1569.69(a)(2) (2) Medication Training- In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D

Per LPA's file reviews staff, 2, 3, and 4 lacked required annual training. This deficiency will be cited,
HSC 1569.625(b)(2) Annual Required Training-In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training, see LIC809D

Deficiencies cited from the 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 Administrator/Licensee Eden Relota.
Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/03/2025 04:29 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/03/2025 at 04:00 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Per LPA's file reviews staff, 2, 3, and 4 lacked required medication training, the licensee did not comply with the section cited above in [3] out of [4] staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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2
3
4
Licensee to ensure staff,2, 3, and 4 obtain required medication training; Licensee to submit proof of training of staff 2,3, and 4 by 3/24/2025. Licensee to submit plan on how facility will be in future compliance, and ensure staff training is obtained, POC due 3/4/25.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/03/2025 04:29 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/03/2025 at 04:00 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Per LPA's file reviews staff, 2, 3, and 4 lacked required annual training, the licensee did not comply with the section cited above in [3] out of [4] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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4
Licensee to ensure staff, 2, 3, and 4, obtain all required annual training hours and topics completed. Licensee to submit proof of training of staff training by 3/24/2025
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
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