496800794-6-29-2021-21-AS-CFGS-C4FM7R-20210629092157

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800794
Report Date: 06/28/2021
Date Signed: 06/29/2021 09:22:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SUNSET HOUSE		FACILITY NUMBER:	496800794
ADMINISTRATOR:	CATTICH, DOUGLAS		FACILITY TYPE:	740
ADDRESS:	9408 WILLOW AVE		TELEPHONE:	(707) 795-7882
CITY:	COTATI	STATE: CA	ZIP CODE:	94931
CAPACITY:	9	CENSUS: 8	DATE:	06/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Douglas Cattich - Licensee/Administrator		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Doug Cattich – Licensee/Administrator. There were 8 residents present at the facility. LPA arrived at the facility and had temperature checked. All staff temperatures checked and logged each shift. Staff placed their masks once LPA arrived. LPA toured the facility with Doug Cattich Licensee/Administrator. During tour on 6/28/2021 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 2/2021 at the time of the visit. A sample of 4 out of 4 Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured between 105.0 degrees F and 113.1 degrees F within acceptable regulations of 105 to 120 degrees F in 2 of 2 client’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility. Facility has PPE supply stored in one of the residents'’ bathroom. Residents’ medications are stored and locked in the kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SUNSET HOUSE	FACILITY NUMBER: 496800794
	VISIT DATE: 06/28/2021

NARRATIVE

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In addition, facility has a designated area for visitors in the front porch and/or in the bedrooms when possible. Visits are been scheduled. Residents have also available telephone calls when contacting with family members and others.Staff had all PPE training required on file and still working towards acquiring N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

There were no deficiencies cited at this time.

Department is requesting the following to be submitted to RO Rohnert Park by July 5^th, 2021 as follows:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Report

Copy of Liability Insurance

Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC809 (FAS) - (06/04)

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