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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803643
Report Date: 12/23/2021
Date Signed: 12/23/2021 10:20:51 AM

Document Has Been Signed on 12/23/2021 10:20 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:SABILE HOUSE OF CAREFACILITY NUMBER:
486803643
ADMINISTRATOR:SABILE, ROSAUROFACILITY TYPE:
740
ADDRESS:388 VALLE VISTA AVENUETELEPHONE:
(707) 315-1941
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 4DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Care Giver, Rogelio Banzon
Administrator, Rosauro Sabile
TIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Sabile House of Care for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Rogelio Banzon, and granted access into the facility. Administrator, Rosauro Sabile arrived 1 hour later.

LPA toured the facility and found the facility is clean, in good repair and at a comfortable temperature with all exits free from obstruction. Exits doors are equipped with working auditory devices. Fire Extinguisher located in the kitchen was found to be charged and serviced on 02/2021. Smoke detectors and carbon monoxide detectors were found to be all operational during the visit. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees F . There is a minimum of one week supply of nonperishable foods and 2 days of perishable foods and the refrigerator was clean. Toxins are stored in key locked cabinets under the kitchen and bathroom sinks. There was an ample supply of hygiene products, linens and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Resident's medication centrally stored and locked. First Aid kit was inspected and found to be appropriate. All bedrooms have lighting & appropriate furnishings. Required postings viewable in public areas. LPA requested Facility to update the Emergency Disaster Plan. LPA also requested the following documents to be sent to the Regional Office, LIC 309, LIC 400, LIC 308, updated facility sketch, LIC 500 and updated liability insurance.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has not been N95 Fit tested. PPE is sufficient in the facility. Staff has not had any training in PPE.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facility Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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