Sunset Garden

Allegation investigated: -Mismanaged medications. -Facility is not following general food service requirements.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Eden Relota, Licensee. The Department received an allegation of mismanaged medications. According to reporting party, there are three staff (S1, S2 & S3) that pass medications, but they pass them on time, or the medications are found in their pockets, or in the cabinet, or they don't know where it is. LPA/Licensee conducted a spot check of residents’ medications, where it was observed that the facility has pre-poured medications for all residents, which were observed placed inside small containers with their names on them, licensee told staff (S2) that they can't pre-pour medications per regulations. LPA asked S2, if there was any resident who takes medications at noon and they responded “no”, but when the medication drawer was opened there was a medication with a yellow label stating “non” for resident (R4). The medication was not in any container because S2 was not aware that R4 had a prescription for noon medication. Continue on LIC9099C... Substantiated Continued from LIC9099... During file review, LPA learned that resident (R2) went to the ER, but there was no SIR submitted to CCL. LPA will address case management reporting requirements. Based interviews conducted with residents (R1, R2, R3, R4 & R5) it was revealed that at times they have been given wrong time for medication like they will receive morning medication instead of night medication. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given.. Another allegation of facility is not following general food service requirements. Per reporting party, food amount served to residents are limited, veggies and fruit once a week, baked beans and crackers are served and that's it. Based on LPA’s observations, LPA toured the kitchen area and observed kitchen is locked with sign that it states, "employee only". Licensee disclosed that they don't want residents inside because they will eat all the food. LPA explained that the kitchen area can't be locked, so licensee stated that it is only at night. Once again, LPA had a conversation with the Licensee regarding food regulation regarding snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. LPA will address it in case management. During kitchen tour, LPA/Licensee observed not enough fruits and vegetables available for residents in care. Upon LPA’s arrival, LPA observed residents were having breakfast served oatmeal, grapes and bananas. While residents were having lunch, salad and peanut butter sandwich with cantaloupe, staff served resident (R3) a cup with cantaloupe, but R3 stated that cantaloupes give them a bad reaction, staff removed the cup immediately, but staff did not document the request from resident in their care notes. Additionally, LPA/Licensee observed that care plans need to be updated for all residents in care, when LPA inquired about administrator involvement in the operation of the facility due to licensee health challenges, licensee stated that administrator is at school and comes “once in a while”. LPA will address in a case management care plans not been updated within the last 12 months and administrator duties. Based on records review, there are two out of six residents who has a special diet including gluten free-celiac disease, diabetic diet, but based on interviews conducted with residents (R1, R2, R3, R4 & R5) the facility does not have fresh fruit or vegetables available only frozen food, residents disclosed that last night dinner it was hamburgers and potatoes, their last lunch it was spaghetti, which some residents don’t think is the adequate meal for them. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. Continued from LIC9099A... An allegation of physical plant. Per reporting party, the facility hasn’t had hot water for three years, the water needs to let it run for a while and even then, it's not warm enough to take a shower. Based on interviews with licensee, it was revealed that hot water takes too long, about 15-20 minutes, which was confirmed by residents. The licensee indicated that they would bring a technician to look at it. Although the water takes too long, water temperature measured within regulations. Based on interviews conducted with residents in care, the allegation of physical plant due to hot water delivery taking over 15 minutes, but water measures within the regulations does not indicate a violation of Title 22 regulations. A finding that the complaint allegation of physical plant is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Last allegation of not maintaining comfortable temperature. Reporting party alleges that It's too cold at the facility, thermostat says 50s, but residents need to have multiple blankets. Sometimes it's too hot and the thermostat says 78. On 8/27/26, the reporting party insistently called licensing to indicate that R1 was very sick with an asthma attack and cold. Based on interviews with the licensee, it was revealed that the temperature is controlled by staff (S2). On 8/20/26, LPA/Licensee observed two residents wearing sweaters, blankets and gloves, thermostat was reading 72 degrees in the morning, so licensee agreed to turn it up to make the home warmer for residents in care. Based on interviews conducted with residents (R1, R2, R3, R4 & R5) in care, it was revealed that S2 controls the temperature of thermostat, which it is locked at all times and apparently it is not working properly because the air conditioning is on all the time, resulting on residents feeling cold all the time, and the facility has provide them with portable heaters. Although the thermostat is locked, LPA/Licensee observed during physical plant tour, the facility was a comfortable temperature of 72 degrees, which is within range according to licensing regulations. A finding that the complaint allegation of comfortable temperature is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Sep 1, 2026 · control 21-AS-20260811145626

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Sep 2, 2026

Type A – 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication… (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on LPA’s observations of medication spot check conducted with S2, records review and interviews with S2 and residents in care, S2 has been mismanaging residents’ medications, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee agrees to conduct a medication audit, retrain staff on medication management to ensure resident medications are properly handled daily. On 8/28/26, Licensee submitted the training records to CCL to clear the citation. Deficiency is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(26) · Plan of correction due date: Sep 15, 2026

Type B- 87555(b)(26) General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on LPAs/Licensee observation and interview, the facility failed to ensure a supply of two days of perishable foods at all times which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee agrees to submit a plan to ensure two days of perishable food is available at facility at all times, submit plan to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Eden Relota. LPA learned through reviewed records and interviews with the licensee that administrator is at school and comes “once in a while”. Based on LPA’s observations during tour of the kitchen area and observed kitchen is locked with sign that it states, "employee only". Licensee disclosed that they don't want residents inside because they will eat all the food. LPA explained that the kitchen area can't be locked, so licensee stated that it is only at night. Once again, LPA had a conversation with the Licensee regarding food regulation regarding snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. During file review, LPA/Licensee observed that care plans need to be updated for all residents in care. Furthermore, LPA learned through file review that resident (R2) went to the emergency room on 7/10/26 and 7/30/26, but the facility failed to submit incident reports as stated by regulations. 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 copy of this report was given.the state’s words, verbatim · CDSS document, Sep 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Sep 2, 2026

Type A- 87405 Administrator - Qualifications and Duties (a)…The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management & administration of the facility… The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement has not been met as evidence by: Based on interviews with Licensee, LPA learned that administrator is not in the premises a sufficient number of hours to provide adequate involvement in the management of the facility, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee agreed to ensure a certified administrator is hired to manage and administer the facility according to applicable laws and regulations. Licensee to submit name of administrator and qualification to CCL by POC date as proof of correction.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(3) · Plan of correction due date: Sep 2, 2026

87468.1 Personal Rights of Residents in All Facilities-(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from...interfering with daily living functions such as eating.... Based on LPA's/Licensee observation during tour of the kitchen area and observed kitchen is locked with sign that it states, "employee only". Licensee disclosed that they don't want residents inside because they will eat all the food, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee will have training conducted focusing on the personal rights of residents and submit to CCL by POC due date to clear the citation.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 15, 2026

Type B – 87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate... This requirement is not met as evidenced by: Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 6 residents care plans needed to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: The facility will submit self-certification (LIC9098) ensuring that all residents' care plans were updated by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Sep 15, 2026

Type B - 87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below…This requirement has not been met as evidence by: Based on LPA’s/Licensee records review and interviews, the licensee failed to notify the department within 7 days of occurrence about R1’s hospitalizations, which poses a potential risk to the health & safety of residents in care.the state’s words, verbatim · CDSS document, Sep 1, 2026

Plan of correction: Licensee agrees to ensure incidents are reported by regulation. Licensee agrees to review regulation 87211 and conduct training for all staff in reporting requirements. Evidence of completed training to be submitted to CCL by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required visit and met with Licensee, Eden Relota. Required postings were observed. Annual fees current. LPA/Licensee initiated a tour of the facility at 12:45pm and observed the following: flies in the kitchen area, there was no uncovered food, walls in the bathroom #2 has cracks & needed to be repaired, three garbage cans in resident rooms require covers/lids and backyard deck in disrepair. LPA had a conversation with Licensee about the importance of having facility maintained in good repair and free of insects. Hot water temperature in resident's bathrooms measured at 115.2 and 113.4 F which is within allowable range of 105 to 120 degrees F. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Medications were centrally stored and locked at time of inspection. Toxins are located in a locked cabinet in the garage. Fire extinguishers were last serviced January 2025. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on 8/10/2025. Facility has a portable generator. Medication and medication records were reviewed. Facility was a comfortable temperature. At approximate 12:50pm LPA/Licensee observed that washcloths were hanging on the bathroom towel bars for resident use in two resident bathrooms that are shared and the bathrooms didn’t have paper towels for resident use to help ensure sanitary hygiene care for all residents. LPA/Licensee discussed about the use of common wash cloths should not be practiced (technical violation issued). Continue on LIC809C... Continued from LIC809... At approximate 1:00pm LPA/Licensee observed that the facility did not have at least two days of perishable, but they have one week of nonperishable food was available. According to Licensee, they were going buy supplies of fruits for residents in care. LPA initiated file review at approximately 1:15pm. Three staff files and six resident files were reviewed. Residents have medical assessments and care plans updated per regulation. All staff have CPR/1st aid certificates and annual required training hours were complete. Administrator Certificate for Mechelle Relota, 7004006740, expires on 5/21/2026. Medication and medication files were reviewed. Contact information was reviewed. During file review, LPA learned about hospitalization of R1 on 9/2/25 through 9/4/25 due to fall, but review of incident reports indicates that the facility did not submit an incident report to the Department. Licensee agreed to provide updated copies of the following by 11/21/25: LIC308 - Designation of Facility Responsibility and LIC 500 Personnel Report. 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 copy of this report was given.the state’s words, verbatim · CDSS document, Nov 7, 2025

The state marks this report as 7 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Magdaleno and Cuadra arrived unannounced to conduct an Annual Required visit and met with Licensee, Eden Relota. Required postings were observed. Annual fees current. LPAs/Licensee initiated a tour of the facility at 1:45pm and observed the following: Facility was a comfortable temperature. However LPAs/Licensee observed the following: Vent in hallway requires cleaning, 5 garbage bags with residents clothing outside, tripping hazard in resident room # 2, lights flickering in bathroom #1, garbage cans in resident rooms require covers/lids. LPAs had a conversation with Licensee about the importance of having facility maintained in good repair. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Hot water temperature in resident's bathrooms measured at 107.2 and 114.2 F which is within allowable range of 105 to 120 degrees F. Medications were centrally stored and locked at time of inspection. Toxins are located in a locked cabinet in the garage. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last serviced January 2025. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on 1/5/2025. Facility has a portable generator. Medication and medication records were reviewed. LPAs initiated file review at approximately 2:15pm. Three staff files and five resident files were reviewed. Residents have medical assessments and care plans updated per regulation. All staff have CPR/1st aid certificates and annual required training hours were complete. Administrator Certificate for Mechelle Relota, 7004006740, expires on 5/21/2026. Medication and medication files were reviewed. Contact information was reviewed. LPAs had a conversation with the Licensee regarding activities (Technical violation issued). Licensee agreed to provide updated copies of the following by 1/31/25: LIC308 - Designation of Facility Responsibility and 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 conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Jan 21, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: -Facility staff is isolating resident to their room. -Facility staff do not ensure that the resident has an adequate amount of water.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with staff Judith Martinez. Licensee was not able to come to the facility, but they were available over the phone and gave permission to staff to sign the report. The Department received an allegation of facility staff isolating a resident in their room. Per Reporting party, the resident (R1) is considered bedridden, and they do not leave their room due to staff is not providing them with the opportunity to interact with the other residents in the home. Based on records review, the facility provided R1’s care plan dated 1/1/2024. According to R1’s care plan, facility staff and their responsible attempts to communicate with them by holding their hand. LPA also was provided with the facility activity calendar that does not include residents who have an ambulatory limitation to help with socialization with other residents in care. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... On 2/6/2024, LPA conducted an unannounced visit and observed that the facility has an activity board that confirmed that it does not include specialized activities that includes residents who have mobility limitations. During the visit, LPA toured R1’s bedroom and observed that their room is shared with another resident (R2) for about a year. Based on confidential interviews conducted by LPA with staff (S1 & S2) and residents in care (R2 & R3), who expressed that they do have a variety of activities as walks, go out for lunch with their families, watch tv, bingo, etc. Based on records review, R1’s physician report dated 12/28/2023 indicates that R1 is non-verbal, requires assistance with turning or repositioning in bed and with their daily activities. Per Licensee, they were aware that admitting a resident in their condition will require them to provide specialized activities, the licensee indicated that they had been trying to enroll R1 in a physical therapy provided by home health, but it was refused by R1’s responsible party. LPA will address the lack of activities provided by the facility with case management. A finding that the complaint allegation of facility staff isolating a resident to their room occurs is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegations of facility staff do not ensure that the resident has an adequate amount of water. Per reporting party, the resident (R1) is not provided with an adequate amount of water. During the investigation, on 2/6/2024 LPA/staff toured the facility including bedrooms used by residents in care. During the tour of the physical plant LPA/staff observed in the shared bedroom for R1 and R2 both residents had a bottle of water on their night table. The bottles of water are half full and there are about 18 ounces of water in each resident's (R1 & R2) bottle. Based on records review, R1’s daily personal care worksheet for the month of January 2024, indicates that the facility had been assisting R1 with bathing, bowel, bedding change, brushing teeth, incontinence, dressing, mobility exercises, grooming, hand care and laundry. LPA obtained Santa Rosa Police Department records of two welfare visits conducted on 2/7/2024 event #SR40001279 and 3/8/2024 event #SR240002413, the findings obtained resulted in an unfounded case disposition. LPA attempted on various dates (3/18/24 at 12:52pm and 3/27/24 at 9:00am) to speak with R1’s responsible parties to gather additional information but was unsuccessful. A finding that the complaint allegation occurs of facility staff do not ensure that the resident has an adequate amount of water is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted with Licensee over the phone and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 21-AS-20240131172927

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with staff Judith Martinez. Licensee was not able to come to the facility, but they were available over the phone and gave permission to staff to sign the report. On 2/6/2024, LPA learned through observation, records review and interviews with Licensee had failed to provide specialized activities to resident (R1) who has mobility limitations. 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 over the phone and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(i) · Plan of correction due date: Apr 19, 2024

87219 Planned Activities (i) Facilities shall provide sufficient equipment and supplies to meet the requirements of the activity program…Special equipment and supplies necessary to accommodate physically handicapped persons or other persons with special needs shall be provided as appropriate. This requirement has not been met as evidence by: Based on observations, records review and interviews with the Licensee did not comply with regulation by not providing specialized activities to resident (R1) which poses a potential risk to health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 5, 2024

Plan of correction: The licensee agrees to draft an updated monthly activity calendar implementing specialized activities as specified on the regulation for persons with mobility limitations. Licensee agrees to send a sample of updated activity calendar to CCL by POC due date to clear the deficiency.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Eden Relota. Required postings were observed. Annual fees current. LPA/Licensee initiated a tour of the facility at 12:30pm and observed the following: Facility was a comfortable temperature and pathways were free from obstructions. Resident rooms were furnished per regulation. Extra linens and hygiene products were available. Hot water temperature in resident's bathrooms measured at 107.4 and 107.2 F which is within allowable range of 105 to 120 degrees F. Medications were centrally stored and locked at time of inspection. Toxins are located in a locked cabinet in the garage. At least two days of perishable and one week of nonperishable food was available. Fire extinguishers were last serviced December 2023. Smoke detectors and carbon monoxide detector throughout the facility were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on 1/5/2024. Facility has a portable generator. Medication and medication records were reviewed. LPA initiated file review at approximately 1:00pm. Four staff files and six resident files were reviewed. One out of six residents (R1) did not have their care plan signed by their responsible party within the last 12 months as stated per regulation. However, their care plan has been updated, LPA will issue a technical violation. Four out of four staff First aid certificates and CPR certificates for staff are current as well as their annual required training hours are complete. Administrator Certificate for Mechelle Relota, 6014149740, expires on 5/22/2024. Medication and medication files were reviewed. Contact information was reviewed. Licensee agreed to provide updated copies of the following by 1/26/24: LIC500 - Personnel Report, LIC308 - Designation of Facility Responsibility, Liability insurance and proof of ownership. No deficiencies cited during today's inspection. Exit interview conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 16, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.