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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 05/05/2022
Date Signed: 05/05/2022 01:48:24 PM


Document Has Been Signed on 05/05/2022 01:48 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 9DATE:
05/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Delia Ulbata, LicenseeTIME COMPLETED:
02:00 PM
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On 5/5/2022 LPA Tobola conducted an unannounced Case Management visit and was greeted by Licensee, Delia Ulbata. The purpose of the visit is to follow up on a self reported AWOL for resident (R1). The Licensee stated that on 4/23/2022 R1 contacted an outside party to be picked up and taken to R1's home in American Canyon. Licensee contacted Vallejo Police Department who located R1 at the American Canyon home. R1 refused to return to the facility from Licensee and Vallejo Police Department request. R1's Power of Attorney had also been notified since 4/23/2022.

LPA conducted interview with Licensee and provided technical assistance regarding the case. In addition LPA gathered resident R1 documents for review. Licensee will be contacting Adult Protective Services. Licensee submitted Unusual Incident Report to CCL Regional Office and provided LPA with a copy of the report.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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