496803760-2-24-2026-21-AS-DALO-DRLTAB-20260224133317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803760
Report Date: 02/24/2026
Date Signed: 02/24/2026 01:34:25 PM

Document Has Been Signed on 02/24/2026 01:34 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 GARDEN II		FACILITY NUMBER:	496803760
ADMINISTRATOR/ DIRECTOR:	RELOTA, EDEN		FACILITY TYPE:	740
ADDRESS:	320 KIVA PLACE		TELEPHONE:	(707) 548-5753
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY: 4		CENSUS: 3	DATE:	02/24/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Eden Relota-Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:50 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, on 2/24/26 at approximately 9:45am, and met with caregivers Dina Camilon and Estelita Cabardo. Staff contacted Administrator Eden Relota, and notified them the LPA was at the facility. The Administrator arrived to meet with the LPA for the annual inspection. 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 drills were completed on 1/20/26, Fire drill, and 12/10/25, Earthquake drill. 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 three (3) residents in care at the facility. Two (2) fire extinguishers were serviced and tagged as required. Facility has a carbon monoxide detector that was working properly during the inspection. The smoke alarms are hard wired, and worked appropriately during the inspection check. LPA reviewed three (3) resident files, including medication records and medication storage. LPA reviewed three (3) staff files. All staff have criminal record clearance as required. LPA reviewed staff training. Staff had required first aid and CPR certification. Hot water was measured at 117.5 degrees Fahrenheit. All exits were clear and free of obstructions. All exits had auditory alarms on the doors; All alarms were working properly during the inspection. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SUNSET GARDEN II	FACILITY NUMBER: 496803760
	VISIT DATE: 02/24/2026

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
26
27
28
29
30
31
32

LPA observed a sufficient supply of food, including fruits, meats, vegetables, grains, dairy, drinks, and other food items for residents' in care. Sufficient furnishings for resident use. Sufficient supply of linens, paper products, cleaners/disinfectants, and personal protective equipment (PPE) supplies. All resident rooms, bathrooms, and common areas had sufficient lighting for residents' use. The home was observed to be at a comfortable temperature. The home was observed to be clean and orderly. The backyard deck has a ramp that leads out the fire exit gate. The fire exit gate opened freely with no obstructions, as required.

LPA is requesting the following documents be updated and submitted by 3/24/26:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610-Emergency Disaster Plan (9 pgs)- if updated, submit copy- No changes, submit copy of last page (signed/dated)
Copy of Current Liability Insurance
Infection Control Plan- if any updates submit a copy- If no changes, submit copy of last page (signed/dated)
Roster of Residents
Copy of current Administrator Certificate

There were no deficiencies cited during today's inspection.
Exit interview was conducted with Administrator Eden Relota.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2026

LIC809 (FAS) - (06/04)

Page: 3 of 3