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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801554
Report Date: 01/21/2025
Date Signed: 01/21/2025 03:40:41 PM

Document Has Been Signed on 01/21/2025 03:40 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 GARDENFACILITY NUMBER:
496801554
ADMINISTRATOR/
DIRECTOR:		RELOTA, MECHELLEFACILITY TYPE:
740
ADDRESS:1018 SUNSET AVE.TELEPHONE:
(707) 528-8512
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
01/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:37 PM
MET WITH:Eden Relota (Licensee)TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Magdaleno and Cuadra arrived unannounced to conduct an Annual Required visit and met with Licensee, Eden Relota. Required postings were observed. Annual fees current.

LPAs/Licensee initiated a tour of the facility at 1:45pm and observed the following: Facility was a comfortable temperature. However LPAs/Licensee observed the following: Vent in hallway requires cleaning, 5 garbage bags with residents clothing outside, tripping hazard in resident room # 2, lights flickering in bathroom #1, garbage cans in resident rooms require covers/lids. LPAs had a conversation with Licensee about the importance of having facility maintained in good repair. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Hot water temperature in resident's bathrooms measured at 107.2 and 114.2 F which is within allowable range of 105 to 120 degrees F. Medications were centrally stored and locked at time of inspection. Toxins are located in a locked cabinet in the garage. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last serviced January 2025. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on 1/5/2025. Facility has a portable generator. Medication and medication records were reviewed.

LPAs initiated file review at approximately 2:15pm. Three staff files and five resident files were reviewed. Residents have medical assessments and care plans updated per regulation. All staff have CPR/1st aid certificates and annual required training hours were complete. Administrator Certificate for Mechelle Relota, 7004006740, expires on 5/21/2026. Medication and medication files were reviewed. Contact information was reviewed. LPAs had a conversation with the Licensee regarding activities (Technical violation issued).
Licensee agreed to provide updated copies of the following by 1/31/25: LIC308 - Designation of Facility Responsibility and Liability insurance.
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 and copy of this report was given.
Victoria BertozziTELEPHONE: (707) 588-5059
Elias MagdalenoTELEPHONE: (707) 588-5045
DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 01/21/2025 03:40 PM - It Cannot Be Edited


Created By: Elias Magdaleno On 01/21/2025 at 03:20 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
FACILITY NUMBER: 496801554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in vent in hallway requires cleaning, garbage bags with residents clothing outside, tripping hazard in resident room # 2, lights flickering in bathroom #1, Garbage cans in resident rooms require covers/lids, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Licensee agreed to fix areas of concern and will submit pictures as proof of correction by POC due date to clear the citation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Victoria Bertozzi
TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME:Elias Magdaleno
TELEPHONE: (707) 588-5045
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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