496800794-7-6-2023-21-AS-SHAN-CTGT5N-20230706142548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800794
Report Date: 07/06/2023
Date Signed: 07/06/2023 02:25:53 PM

Document Has Been Signed on 07/06/2023 02:25 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 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: 9	DATE:	07/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Douglas Cattich, Licensee/Administrator		TIME COMPLETED:	02:30 PM

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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by Licensee/Administrator Doug Cattich. There is a total of 9 residents, 4 are dementia residents. There is no resident currently on Hospice. LPA toured the facility on 7/6/2023 at 10:40 AM with Licensee/Administrator Doug Cattich; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices, and all doors were activated at the time of the visit. Fire Extinguisher was found to be last charged on 4/27/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 112.6 degrees F and 115.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 7/6/2023 at 10:55 AM. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room of the facility. Dangerous items are stored inaccessible to residents with dementia. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Medications were centrally stored in two locked cabinets in the facility kitchen by front living room of the facility. A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 12:30 PM on 7/6/2023 and learned that 5 of 5 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. Continued on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSET HOUSE	FACILITY NUMBER: 496800794
	VISIT DATE: 07/06/2023

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LPA reviewed a sample of staff records at 1:15 PM on 7/6/2023 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received the additional training required. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed. Doug Cattich Administrator Certificate # 6007381740 expires on 8/23/2023. Disaster Drills have been conducted quarterly with the last one being conducted on 4/4/2023.

LPA initiated a file review of five resident files and four personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023

LIC809 (FAS) - (06/04)

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