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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600105
Report Date: 09/16/2019
Date Signed: 09/17/2019 08:39:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHATEAU SABELLEFACILITY NUMBER:
415600105
ADMINISTRATOR:MORALES, GABRIELAFACILITY TYPE:
740
ADDRESS:2921 ISABELLE STREETTELEPHONE:
(650) 341-2296
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
09/16/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Nancy Castle, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Raygoza conducted an unannounced 1 year required inspection. LPA met with Administrator, Nancy Castle and stated purpose of visit. LPA toured the facility with the Administrator.

LPA began tour in the kitchen and observed sufficient food supply for 6 residents. LPA checked the two-day perishable and seven day nonperishable supply to be sufficient. Food replenished weekly and disposed of weekly. Facility appears to be clean and in good repair. LPA toured bedrooms and all have adequate lighting and furniture. Linen closet has ample clean linen and bedspreads. CCL forms were visibly posted along with Ombudsman poster. During visit, there were 6 residents in care and two caregivers present. All six residents are non-ambulatory residents. Hot water was tested and measured at 118 degrees F. Resident's main bathroom shower is equipped with grab bars and non-slip mats.

Facility is equipped with a fire alarm, smoke detectors and carbon monoxide detector. Disaster/Fire evacuation drills conducted every 3 months. The room temperature was observed to be comfortable. Cleaning solutions were locked in storage area in garage. Resident records randomly reviewed. Staff files and records randomly reviewed. The facility was observed to have a valid Administrator and certificate expires 4/3/2020.

The following forms to be submitted to CCL Office by 9/30/19:
LIC 308 Administrative Responsibility Designation
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
No deficiency cited.
This report was reviewed, discussed and a copy given to Nancy Castle, Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2019
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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