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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803848
Report Date: 05/29/2024
Date Signed: 05/29/2024 02:35:21 PM

Document Has Been Signed on 05/29/2024 02:35 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 IIIFACILITY NUMBER:
496803848
ADMINISTRATOR/
DIRECTOR:		RELOTA, EDENFACILITY TYPE:
740
ADDRESS:1144 PRUNETREE CTTELEPHONE:
(707) 548-5753
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:28 PM
MET WITH:Eden Relota (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management visit and met with staff John Semilla Licensee, Eden Relota arrived later. Currently there are five residents in care.

On 5/22/24 LPA received a call from Licensee notifying the Department that their facility's lease agreement has not been renewed due to landlord wants to sell the property. Per Eden, they have unsuccessfully applied to buy the home. However, the selling price is too high and not worth it to buy the property. Based on records review, the terms of the lease agreement expired as of March 31, 2024. On April 23, 2024 the landlord of the facility have issued a 60-day eviction notice to the licensee to vacate the premises by June 22, 2024. However, the licensee provided 30-day eviction notices to the residents and their responsible parties dated May 24, 2024. Upon receipt of eviction notices and written closure plan, it was determined that the eviction notices were unlawful due to the lack of required unlawful detainer statement. Also, the licensee is notifying the residents about the change of use of the facility, but not providing them at least with 60-days to leave the premises as stated per regulation. On 5/27/24, the licensee submitted a letter sent to the landlord requesting an additional 30-days to vacate the property, which it has not received a response from the landlord as of today.

During today's visit, LPA toured the building and grounds and verified facility has two staff on duty providing care and supervision to five residents. Per Eden, the resident's responsible parties are in agreement to get their loved ones relocated to their sister facility Willows Nursing Home #496804217, which is currently pending a subsequent visit to obtain a license. Licensee agreed to review, issue and re-submit lawful 60 days eviction notices to Community Care Licensing and the resident's responsible parties to comply with regulation.

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 a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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 05/29/2024 02:35 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 05/29/2024 at 02:02 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 III
FACILITY NUMBER: 496803848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87224(a)(5)(A)(1)

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87224 Eviction Procedures (a)(5)Change of use of the facility.(A) The licensee may upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. (1)...written notice to evict due to change of use of the facility shall be made to the resident or the resident’s responsible person and shall include all requirements specified in Section 1569.682(a)(2)(A) through (F) of the Health and Safety Code
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Licensee agreed to review, issue and provide lawful eviction notices including unlawful detainer statement to all residents in care, their responsible parties and CCL by POC due date of 6/3/24 to clear the deficiency.
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Based on records review and interviews with licensee did not comply with above section by not providing residents and their responsible parties with a lawful eviction notice including providing at least 60 days written notice, which poses a potential risk to the health & 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 Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024


LIC809 (FAS) - (06/04)
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