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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 07/26/2021
Date Signed: 07/26/2021 01:24:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:RODELOU CARE HOMEFACILITY NUMBER:
486803661
ADMINISTRATOR:ULBATA, DELIA MFACILITY TYPE:
740
ADDRESS:431 EBBETS PASS ROADTELEPHONE:
(707) 552-7347
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:10CENSUS: 6DATE:
07/26/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Delia Ulbata, AdministratorTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Lopez and Tobola conducted an unannounced Required 1 year inspection to Rodelou Care Home and met with Administrator Delia Ulbata. LPAs called the facility to conduct a risk assessment call prior to visit. Staff and Administrator were observed to be wearing masks during facility tour. Facility provides care for 6 residents some of which with a diagnosis of dementia.

LPAs toured the facility on July 26th, 2021. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on February 16, 2021 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly. There was a ample supply of both perishable and nonperishable foods as required by Title 22 Regulations. LPAs observed Resident R1's blood test kit sharps container in R1's bedroom and two gardening sheers located in the backyard accessible to residents in care. The blood test kit sharps were removed from R1's bedroom and placed in the medicine cabinet. Gardening sheers were immediately removed and placed in locked closet located in the laundry room.

There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. LPAs observed razor blades in an unsecured shower room accessible to clients with dementia. Shower room was immediately locked. In addition, LPA's observed a box of over the counter medications located in Resident R2's bedroom accessible to residents with dementia which were immediately removed. LPA's also observed 3 disarmed auditory alarms located in R2's bedroom, backyard and front doors.

Facility has submitted a mitigation program plan and LPAs reviewed at the time of visit. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, thermometer and other items designated for visitors and staff before coming into work. Staff and residents are being monitored 1x/day and results are documented in a binder for each month. Facility has PPE supplies stored in a designated location. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has conducted staff training on infection control.



No deficiencies observed or cited during today's Required 1- Year inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021
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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