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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800794
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:30:05 PM


Document Has Been Signed on 07/25/2024 04:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SUNSET HOUSEFACILITY NUMBER:
496800794
ADMINISTRATOR:CATTICH, DOUGLASFACILITY TYPE:
740
ADDRESS:9408 WILLOW AVETELEPHONE:
(707) 795-7882
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY:9CENSUS: DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee Douglas CattichTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Licensee Douglas Cattich. Facility contact information was reviewed.

At approximately 2:00pm LPA and licensee toured the building and grounds. The facility was found to be at a comfortable temperature. Half bath in room #3 has leaking faucet. Sink does not have vanity to cover plumbing, underneath the sink faucet there was a trash can to collect the water from leaking . The underside of the faucet was covered entirely in black substance. Room #5 had clogged toilet and feces on the floor on top of towel around bottom of toilet. Main bath next to room #3 has black substance around the bottom perimeter of the inside of the shower and brown film covering shower curtain, especially on bottom edge. Very dim light in bathroom so LPA could not confirm if black substance was covering exposed particle board or covering the entire surface of tile. Also, main bath does not have an exhaust fan. LPA discussed with licensee it may mitigate black substance growth and brown film growth if the bathroom had a method by which it could be ventilated (deficiency cited, see 809D).

LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Kitchen drawer had rodent dropping present (deficiency cited, see 809D).

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required grab bar but missing non-skid mat. Water temperature in sink accessible to residents in care measured at 108.3 degrees F which is within the allowable range of 105 to 120 degrees F.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SUNSET HOUSE
FACILITY NUMBER: 496800794
VISIT DATE: 07/25/2024
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Continued from 809...

Fire extinguishers were last inspected 4/30/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drill was 4/20/2024. Facility has a backup generator for use during a power outage.

At approximately 3:00pm LPA conducted a review of 9 resident records. At approximately 3:30pm LPA conducted review of 5 staff records. All required documentation present.



At approximately 4:00pm LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies

Douglas Cattich Administrator Certificate 7002018740 expires 8/12/2025. All fees are current as of this time. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.



Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Bacterial Water analysis

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with licensee and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/25/2024 04:30 PM - It Cannot Be Edited

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 HOUSE
FACILITY NUMBER: 496800794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that half bath in room #3 has leaking faucet. The underside of the faucet was covered entirely in black substance. Room #5 had clogged toilet and feces on the floor on top of towel around bottom of toilet. Main bath next to room #3 has black substance around the bottom perimeter of the inside of the shower and brown film covering shower curtain, especially on bottom edge, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Facility to repair leaking sink in room #3. Facility to submit work order for fixed faucet along with paid invoice. Facility to submit pictures of replaced or cleaned faucet free from any substance that could be toxic or a danger to residents by plan of correction due date. Facility to remove all black substance from shower in main bathroom next to room #3. Facility to submit pictures with shower free from any substance that could be toxic or a danger to residents by plan of correction due date. Facility to replace shower curtain with clean shower curtain free from any film or substance that could be toxic or a danger to residents by plan of correction due date and submit pictures of shower curtain. Facilty to submit LIC9098 self-certifying that all rooms will be free from soiled linens and ensure that human waste is not found outside of toilets by plan of correction due date.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and licensee observation, the licensee did not comply with the section cited above in that rodent droppings found in kitchen drawer which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Facility to submit work order and paid invoice from pest company for treatment for rodents by plan of correction due date. Work order and invoice must be on official letterhead of pest company.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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