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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 06/26/2024
Date Signed: 06/26/2024 02:50:47 PM


Document Has Been Signed on 06/26/2024 02:50 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: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: 8DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Delia Ulbata, LicenseeTIME COMPLETED:
03:10 PM
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At approximately 11:30 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Delia Ulbata, Licensee/Administrator. The facility is a single story home licensed for ten (10) non-ambulatory residents and a hospice waiver capacity of two (2). The facility currently provides care for 8 residents and there is one resident under hospice care at this time.

At approximately 11:45 AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected ,There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room and kitchen. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 109 and 113 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Thirteen out of thirteen Smoke Detectors and two out of two Carbon monoxide detector were present inspected. There was enough lighting in all common areas, resident rooms, and hallways.

Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order.



Continued on LIC809-Ca
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
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 5


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: RODELOU CARE HOME
FACILITY NUMBER: 486803661
VISIT DATE: 06/26/2024
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Continued from LIC809

At approximately 12:25PM, LPA reviewed Eight out of Eight resident records which were all found to be well organized but missing the required documentation(Updated LIC602, Signed LIC613, LIC601). At approximately 1:00 PM, LPA reviewed two out of two staff records which did not include Administrator's staff file but not on site. LPA advised Administrator all required documentation must be kept at the facility and accessible to CCLD/LPA. LPA advised citation was given on 07/23/23 for missing training files Civil Penalties assessed for repeat violation. Medication records are thorough and contained physician's orders for each resident.

Administrator Administrator Certification is current and expires on 06/23/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident's
LIC610- Disaster Plan (updated with non-local evacuation site)
Staff Training Records including First Aid for all staff
Updated LIC602 for all residents
Signed LIC613 for all residents
LIC601 for all residents
Evidence of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in additional civil penalty assessment.


This report was reviewed with Delia Ulbata and Appeal rights were given.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/26/2024 02:50 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: RODELOU CARE HOME
FACILITY NUMBER: 486803661

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 3 out of 3 staff training record files. Staff are in need of updated annual RCFE training, First Aid, Dementia, and Medication Administration which poses/posed a potential health & safety risk to persons in care.
POC Due Date: 07/06/2024
Plan of Correction
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Licensee agrees to schedule annual training courses for all staff in need of updating. Licensee to provide LIC9098 Proof of Corrections for with schedule date of training to CCLD by POC date 7/06/2024. Once annual training is completed Licensee is to provide training to CCLD for review.

Type B
Section Cited
CCR
87467(a)(3)
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.



This requirement is not met as evidenced by:
Deficient Practice Statement
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No violation -Licensee uses Resident Appraisals which are up to date
POC Due Date: 07/06/2024
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: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR NAME: Stefanie MutialuTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5