496803760-1-11-2024-21-AS-DALO-CZE48N-20240111175301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803760
Report Date: 01/11/2024
Date Signed: 01/11/2024 05:53:10 PM

Document Has Been Signed on 01/11/2024 05:53 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 GARDEN II		FACILITY NUMBER:	496803760
ADMINISTRATOR:	RELOTA, EDEN		FACILITY TYPE:	740
ADDRESS:	320 KIVA PLACE		TELEPHONE:	(707) 548-5753
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	4	CENSUS: 4	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Marife Davis-Caregiver		TIME COMPLETED:	06:00 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	Licensing Program Analyst(LPA) Alviso arrived unannounced to conduct a Required -1 Year inspection and met with caregiver Marife Davis. There were two other caregivers at the facility, Robert White, and Estelita Cabardo. Robert contacted Administrator Eden Relota, and notified them the LPA was at the facility. The Administrator arrived to meet with the LPA. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. The facility has a required infection control plan. The facility has a required emergency and disaster plan. Per file review, last fire drill was completed on 12/5/23. Licensee is completing fire/evacuation/emergency drills quarterly as required. Fire clearance is approved for four (4) non-ambulatory, of which one(1) may be bedridden. There were four (4) residents in care at the facility; One (1) resident currently on hospice care. LPA reviewed four (4) resident files. All files were complete. LPA reviewed four (4) staff files. All staff have criminal record clearance as required. All staff have annual training. All staff have required First Aid & CPR certification. LPA toured the facility with the Administrator. All exits were unobstructed. Fire extinguisher was serviced and tagged as required- expires 5/9/24. Carbon monoxide detector was working properly during the inspection. All smoke alarms were working when checked during the inspection. All bathroom(s) had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Sufficient food supply, perishables and non-perishables. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSET GARDEN II	FACILITY NUMBER: 496803760
	VISIT DATE: 01/11/2024

NARRATIVE

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Cleaners/toxins were observed to be locked up and inaccessible to residents in care. Facility was at a comfortable temperature during the inspection. LPA observed the facility to be clean and orderly.LPA requested

Licensee to update the following documents by 2/11/2024.
LIC 308 Designated
LIC 500 Personnel Summary-all staff names/titles-days/hours working
LIC 610E Emergency Disaster Plan- update as needed-submit copy-if not updated-submit copy of review page signed/dated.
Infection Control Plan- update as needed-submit copy-if not updated-submit copy of review page signed/dated.
LIC 9020 Register of Facility Client’s/Resident’s.
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.if handling cash

LPA observed the following deficiencies:
LPA observed a plastic container in the refrigerator with medications unlocked, accessible to residents, and to any others in the facility that don't handle medications. Cited, Incidental Medical and Dental Care Services Section 87465(h)(2) - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.

The following deficiency(s) was/were cited from 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 with the Administrator. Appeal Rights provided to the Licensee/Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 05:53 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 II	FACILITY NUMBER: 496803760
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services Section 87465(h)(2) - Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed a plastic container in the refrigerator with medications unlocked, accessible to residents, and to any others in the facility that don't handle medications. the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	CORRECTED BY LICENSEE PURCHASING A LOCK BOX AT A LOCAL STORE TO CENTRALLY STORE THE RESIDENT MEDICATIONS NEEDING TOBE REFRIGERATED. LICENSEE WILL HOLD AN INSERVICE WITH ALL STAFF ON FACILITY MEDICATION POLICY AND PROCEDURES. SUBMIT PROOF OF TRAINING BY 1/19/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024

LIC809 (FAS) - (06/04)

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