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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600105
Report Date: 10/02/2024
Date Signed: 10/02/2024 02:17:15 PM

Document Has Been Signed on 10/02/2024 02:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CHATEAU SABELLEFACILITY NUMBER:
415600105
ADMINISTRATOR/
DIRECTOR:		MORALES, GABRIELAFACILITY TYPE:
740
ADDRESS:2921 ISABELLE STREETTELEPHONE:
(650) 341-2296
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:LIcensee TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 10/02/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with caregivers initially then later during the visit the licensee/administrator Nancy Castle arrived to meet with LPA. There are currently 6 residents in the facility during today's visit and 3 staff present.

This is a multi-level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 4 hospice residents. Residents do not reside on the upper floor as that floor is for staff only. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are cameras posted around the outside of the facility and in common areas inside the facility such as the dining room, hallway, and other areas. LPA observed the facility kitchen which is clean and observed appliances that are in good repair. Knives are stored and locked in a cabinet next to the stove. Perishable and non-perishable food supplies are in place. There are additional refrigerators in the garage area which carries additional food supplies for resident use. First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in a cabinet in the dining room. LPA observed at least two fire extinguishers in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. PPE is observed to be in place. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted 04/10/2024. Technical violation is discussed regarding conducting such drills quarterly. Water temperature was measured at 105F. Cleaning supplies are observed to be locked in the garage.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHATEAU SABELLE
FACILITY NUMBER: 415600105
VISIT DATE: 10/02/2024
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LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floors are equipped with non-skid mats or flooring. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 5 resident files. 2 resident files did not have current physician reports for R2 and R3 both of whom have a diagnosis of dementia Resident with dementia require an annual physicians report. This poses an immediate health and safety risk.. Also, residents only had preplacement appraisals on file but no needs and service plans. LPA advised on having appraisal needs and service plans on file via technical assistance. 3 staff files are also reviewed as current. Administrator certificate is observed as current expiring 04/04/2026 per certificate observed on site.

The following updated forms are requested to be submitted to CCLD by 10/09/2024:

• Copy of all updated administrator certificate
• Copy of staff first aid cards
• Copy of facility's liability insurance
• Copy of facility resident roster
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Citations are issued on the following LIC809D. Technical violation is discussed on the following LIC9102TV and LIC9102TA. Report is reviewed with co-administrator Armand Atienza.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/02/2024 02:17 PM - It Cannot Be Edited


Created By: Jaime Vado On 10/02/2024 at 01:40 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHATEAU SABELLE
FACILITY NUMBER: 415600105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2024
Section Cited
CCR
87705(c)(5)

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87705(c)(5) Care of Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by:
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Licensee shall develop a plan to maintain all residents with dementia physician's reports to be kept up to date annually. Report and evidence of R2 and R3 updated physician's report to be sent to the department.
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Based on records reviewed, LPA observed that the physician's report for R2 and R3 is not current. Residents with dementia require a new physicians report annually. This poses an immediate health and safety risk to resident 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:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024


LIC809 (FAS) - (06/04)
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