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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803760
Report Date: 09/28/2021
Date Signed: 09/28/2021 11:44:33 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210611113332
FACILITY NAME:SUNSET GARDEN IIFACILITY NUMBER:
496803760
ADMINISTRATOR:CHERNIZER, OFELIAFACILITY TYPE:
740
ADDRESS:320 KIVA PLACETELEPHONE:
(707) 548-5753
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:4CENSUS: 4DATE:
09/28/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Eden Relota/AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained unexplained bruising
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned Complaint Allegation. LPA met with Administrator and discussed the findings. On or about May 28, 2021, R1 was noted to have bruising and small round scabs on both arms. Personnel from Sonoma County Sheriff's Office noted the bruising but did not find that the bruises were intentionally caused by staff. This Department has interviewed staff and witnesses and reviewed documents. The following determinations are made: R1 sustained bruises that may have been caused by pinching or from other actions; R1's family is satisfied with R1's care and does not suspect staff abuse; Three outside professionals who have observed the bruises and staff interactions with R1 have expressed concerned that the bruises may have resulted from unintentional staff actions; R1's physician has indicated that R1 bruises easily; No definitive cause for the bruising has been determined and the bruising remains unexplained. Based upon the statements and records reviewed, the preponderance of evidence standard has been met. Therefore, the complaint is SUBSTANTIATED.
****Continued on second page******
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20210611113332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GARDEN II
FACILITY NUMBER: 496803760
VISIT DATE: 09/28/2021
NARRATIVE
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The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20210611113332
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 GARDEN II
FACILITY NUMBER: 496803760
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in all Facilities. Residents in all residential care facilities for the elderly shall have.. the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

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Licensee to provide personal rights training for all staff. Licensee has recently provided refresher training for all staff on safe transferring methods for residents. Proof of training to be submitted to CCL by POC date in order to clear the deficiency.
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**Based upon interviews conducted and documents reviewed, Licensee did not provide a safe environment for 1 of 4 residents which posed a potential risk to the health and safety of clients 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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3