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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801554
Report Date: 04/05/2024
Date Signed: 04/05/2024 01:23:14 PM


Document Has Been Signed on 04/05/2024 01:23 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 GARDENFACILITY NUMBER:
496801554
ADMINISTRATOR:RELOTA, MECHELLEFACILITY TYPE:
740
ADDRESS:1018 SUNSET AVE.TELEPHONE:
(707) 528-8512
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Judith Martinez (staff)TIME COMPLETED:
01:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with staff Judith Martinez. Licensee was not able to come to the facility, but they were available over the phone and gave permission to staff to sign the report.

On 2/6/2024, LPA learned through observation, records review and interviews with Licensee had failed to provide specialized activities to resident (R1) who has mobility limitations.

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

Exit interview conducted with Licensee over the phone and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
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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Document Has Been Signed on 04/05/2024 01:23 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SUNSET GARDEN
FACILITY NUMBER: 496801554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/19/2024
Section Cited
CCR
87219(i)

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87219 Planned Activities (i) Facilities shall provide sufficient equipment and supplies to meet the requirements of the activity program…Special equipment and supplies necessary to accommodate physically handicapped persons or other persons with special needs shall be provided as appropriate. This requirement has not been met as evidence by:
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The licensee agrees to draft an updated monthly activity calendar implementing specialized activities as specified on the regulation for persons with mobility limitations. Licensee agrees to send a sample of updated activity calendar to CCL by POC due date to clear the deficiency.
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Based on observations, records review and interviews with the Licensee did not comply with regulation by not providing specialized activities to resident (R1) which poses a potential risk to health and safety of 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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