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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 07/22/2022
Date Signed: 07/22/2022 03:01:54 PM


Document Has Been Signed on 07/22/2022 03:01 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:
07/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Delia Ulbata, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Required 1 year inspection to Rodelou Care Home and met with Administrator, Delia Ulbata. Staff and Administrator were observed to be wearing masks during facility tour. Facility provides care for 9 residents some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with the Administrator. 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 January, 26 2022 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. LPA observed outdoor storage unlocked containing cleaning supplies and a pair of gardening sheers located outside of the shed accessible to residents in care. Gardening sheers were immediately removed and placed in the outdoor shed and new padlock was put in place.

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. LPA also observed spider webs along the corner of the ceilings in the resident restroom and in resident bedrooms. Upon review of staff records LPA found that 2 out of 3 staff do not have 1st Aid & CPR training.

Facility has submitted infection control plan for review. 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 daily for symptoms and temperature. Facility has PPE supplies stored in a designated location. Facility has a 30-day supply of medication for residents.

Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 486803661
VISIT DATE: 07/22/2022
NARRATIVE
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LPA requested the following documents be sent to CCL by COB 9/1/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance


Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Due to printer technical issues LPA provided copy of electronic report to Administrator. Appeal Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 07/22/2022 03:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODELOU CARE HOME
FACILITY NUMBER: 486803661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 garden sheers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2022
Plan of Correction
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Licensee immediately removed and secured the item. Licensee understands to keep potentially dangerous items inaccessible to residents. Plan of Correction completed at the time of visit.
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 07/22/2022 03:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: RODELOU CARE HOME
FACILITY NUMBER: 486803661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed resident restroom and bedroom with spider webs located on the corner of ceilings, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee agrees to review regulations 87303 and submit a Proof of Corrections LIC9098 confirming the regulation has been reviewed and that the facility will remain in compliance. Licensee agrees to clean spider webs in each bedroom, restroom and common areas. LIC9098 form to be submitted to CCLD by POC due date 8/1/2022.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

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 2 out of 3 first aid & CPR certifications which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Licensee agrees to schedule training for all staff to updated 1st Aid & CPR training. Licensee is to submit LIC9098 Proof of Corrections form with training date by POC due date 9/1/2022. In addition, Licensee is to submit copies of completed 1st Aid & CPR training to CCLD once completed.

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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4