486803661-7-20-2023-21-AS-DTOA-CTWSD9-20230720134645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:46:54 PM

Document Has Been Signed on 07/20/2023 01:46 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 HOME		FACILITY NUMBER:	486803661
ADMINISTRATOR:	ULBATA, DELIA M		FACILITY TYPE:	740
ADDRESS:	431 EBBETS PASS ROAD		TELEPHONE:	(707) 552-7347
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	10	CENSUS: 7	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Delia Ulbata, Licensee		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/20/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Licensee, Delia Ulbata. The facility is licensed for 10 non-ambulatory residents and a hospice waiver capacity of 2. The facility currently provides care for 7 residents. In addition, there is 1 resident that is receiving hospice services and none of which with a diagnosis of dementia. LPA arrived at the facility and observed appropriate signage for COVID protocols and client personal rights posted. LPA continued with a tour of the facility with Licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 2/7/2023 at the time of visit. The facility has installed new interconnected smoke detectors which were tested and found to be in working order. Carbon monoxide detector located in the hallway was also tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the facility laundry room. 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 was measured at faucets accessible to residents and measured between 112.8 and 116.9 degrees F which is within regulation. LPA reviewed facility files and found liability insurance updated. LPA observed appropriate evacuation map located in the front room of the facility. Fire drills are also conducted every 3 months, are recorded and signed off by staff and residents. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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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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: 07/20/2023

NARRATIVE

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Medications located in designated cabinet and were found to be secured. LPA also observed refrigerated mediation to be locked in a separate refrigerator. LPA conducted a review of medication records and found all administering records to be in order. Facility receives medication deliveries direct from pharmacy or picked up by Licensee. During the review, LPA observed medications for residents (R6 & R7) that receive multiple prescriptions to be prepared under a 24 hour period but for the upcoming shifts. LPA explained to Licensee that prescriptions are not to be transferred between containers. Licensee will be reaching out to R6 & R7's physicians to request for guidance and an order on preparing medications prior to administering. Licensee to provide update to CCLD and will be administering medications directly until physician's orders are granted. LPA provided Technical Advisory.

Residents were observed interacting with staff in the common area, watching television, interacting with staff or meeting with visitors for leisure. The exit located in the backyard was found to be unobstructed. All auditory alarms leading out of the facility were tested and found to be in working order.

LPA conducted a sample file review for staff and found all staff to have appropriate 1st Aid & CPR certification on file. Upon review of records, LPA found that all staff are in need of their annual training to be updated. LPA also conducted a file review for all residents. Upon review, LPA found that residents (R2, R3, R5, R6 & R7) require an updated Needs & Service Plan completed. There have not been any major changes of condition. Technical Violation Issued. Administrator prepared forms during the visit and will be working with residents and conservators to update.

Delia Ulbata 6035695740 Administrator Certification application and payment was received by the Department and confirmed on 5/16/2023.

LPA requested the following documents be sent to CCL by COB 8/20/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 01:46 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: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(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
1 2 3 4	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, which poses/posed a potential health & safety risk to persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	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 7/31/2023. Once annual training is completed Licensee is to provide training to CCLD for review.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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