486803661-5-12-2025-21-AS-EMAO-DGLTFQ-20250512144156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803661
Report Date: 05/12/2025
Date Signed: 05/12/2025 02:42:12 PM

Document Has Been Signed on 05/12/2025 02:42 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 HOME		FACILITY NUMBER:	486803661
ADMINISTRATOR/ DIRECTOR:	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: 10	DATE:	05/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Delia Ulbata, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:00 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	At approximately 10:40 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Administrator Delia Ulbata. Facility is a Residential Care Facility for the Elderly (RCFE) with ten (10) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for two (2), with one(1) Hospice residents currently in care and is approved for all non-ambulatory residents. At approximately 11:40 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 2/25. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Water temperature measured 113.3 degrees F and 115.5 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food. There is a shaded seating area in the backyard with outdoor space for activities. Facility has an internet access device designated for resident use and internet service available. Facility telephone was tested and operational during inspection. LPA observed that that one (1) of two (2) backyard gates was in need of repair with boards of wood falling off when LPA attempted to open it (deficiency cited). Continued 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 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: 05/12/2025

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
26
27
28
29
30
31
32

Continued from 809...

Facility conducts quarterly disaster drills, and the most recent drill was conducted 2/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 3/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights.

At approximately 12:45 PM LPA conducted a review of five (5) resident records. All required documentation present.

At approximately 1:30 PM LPA conducted review of two (2) staff records. All required documentation present.

At approximately 2:00 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked.

Delia Ubata Administrator Certificate 6035695740 expires 6/23/2025. All fees are current as of this time.

Updated copies of the following documents were gathered during this visit:
Liability Insurance
LIC500 - Personnel Report
LIC610E - Emergency Disaster Plan

Updated copies of the following documents shall be submitted to CCL within 30 days of this visit:
LIC400 - Affidavit Regarding Client Cash Resources
LIC308 - Designation of Responsibility

Deficiencies are cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights were provided.
Exit interview conducted with Administrator, whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 05/12/2025 02:42 PM - It Cannot Be Edited

Created By: Elias Magdaleno On 05/12/2025 at 02:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RODELOU CARE HOME	FACILITY NUMBER: 486803661
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in One (1) of two (2) gates in backyard was in need of repair with the top boards falling off when LPA attempted to open it which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/05/2025
	Plan of Correction
1 2 3 4	Licensee to submit photo proof that gate has been repaired by Plan of Correction due date 6/5/2025

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.

	Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:

	Elias Magdaleno
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5