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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803643
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:30:25 PM


Document Has Been Signed on 12/28/2023 02:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SABILE HOUSE OF CAREFACILITY NUMBER:
486803643
ADMINISTRATOR:SABILE, ROSAUROFACILITY TYPE:
740
ADDRESS:388 VALLE VISTA AVENUETELEPHONE:
(707) 315-1941
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 5DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Maria DuenasTIME COMPLETED:
02:45 PM
NARRATIVE
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured with Caregiver Maria Duenas.

This facility currently five residents. This facility has a fire clearance for six non-ambulatory residents. There are four private resident rooms and one shared resident room. The shared resident room has a full private bathroom. One of the private rooms has a private bathroom. There is one full common bathroom. There are several common areas. Food supply meets regulations. There is a detached garage that has an employee/office area in it. The backyard has a wood deck and a ramp.

Two resident records were reviewed
Four staff records were reviewed.

The following deficiencies were observed today:
-the annual fees have not been paid for a couple of years. The total amount due as of today is $1,237.00.
-the staff records reviewed showed the most recent training was November 2022. All past training records show November as the month for training. LPA did not find any training for 2023.

The following shall be updated and submitted to Community Care Licensing Division (CCLD) by January 26, 2024:
-updated control of property. The lease agreement on file in the CCLD office shows the lease expired in January 2022
-current liability
-LIC 500 facility personnel or staff schedule

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 12/28/2023 02:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87156(b)(1)(F)

Licensing Fees. In addition to fee set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not paying the annual fee which as of 12/28/2023 equals a total of $1237.00, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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The licensee shall pay the annual fee and then submit in writing how they shall ensure the annual fees are paid by the annual 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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/28/2023 02:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four staff records were found with the most recent training of November 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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By 01/26/2024, the licensee shall ensure all staff have annual training logs updated and current by the annual due dates of the training that are available for review by Community Care Licensing Division.
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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3