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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803848
Report Date: 07/07/2023
Date Signed: 07/07/2023 02:54:14 PM


Document Has Been Signed on 07/07/2023 02:54 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:RELOTA, EDENFACILITY TYPE:
740
ADDRESS:1144 PRUNETREE CTTELEPHONE:
(707) 548-5753
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 3DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Eden Relota (Licensee)TIME COMPLETED:
03:09 PM
NARRATIVE
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Licensing Program Analyst, Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Eden Relota.

LPA/Licensee initiated a tour of the facility around 12:40pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Two fire extinguisher was last serviced January 2023. One carbon monoxide detector in the hallway was tested and properly working. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Required postings were observed. Administrator Certificate for Eden Relota, 6022585740, expires on 11/25/24. Medications were centrally stored and locked. Hot water temperature reading was 111 and 110.8 degrees which is within regulation. Last fire/disaster drill was 3/15/23. LPA initiated file review at 1:00 pm. LPA reviewed five residents files and three staff files. All residents files have a current medical assessment and care plans updated within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training. At approximate 1:30pm LPA/Licensee conducted a spot check of medication and found resident's (R1 & R2) medication was not logged into the Centrally Stored Medication including two out of six medications for R1 as following: Metiracetam 500mg tab and Primidone 50mg tab.Two out of eleven medications for R2: Calcium 500 mg tab and Vitamin D3 25mcg tab. Licensee agreed to review and update the Centrally Stored Medication Records.

Licensee agreed to submit updates of the following documents by 7/21/23: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of 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 was conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
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 07/07/2023 02:54 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 III
FACILITY NUMBER: 496803848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of three residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2023
Plan of Correction
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Licensee agreed to review medication records for all residents and will conduct medication training with staff. Licensee will submit a self-certification LIC9098 form along with training dates for staff to CCL by POC due date.
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2023
LIC809 (FAS) - (06/04)
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