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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803643
Report Date: 11/23/2022
Date Signed: 11/23/2022 02:44:15 PM

Document Has Been Signed on 11/23/2022 02:44 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: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: 5DATE:
11/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Rosauro Sabile, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by staff, Rodger Banzon. Administrator, Rosauro Sabile arrived later during the visit. The facility currently provides care for 5 residents some of which with a of diagnosis of dementia and none of which receiving hospice services.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Staff and Administrator. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/7/2022 at the time of the visit. Smoke and carbon monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Residents are provided various alternative food options per meal with the facility ensuring well balanced and nutritious foods. Residents were observed to be engaged with staff in the living room area participating in television and conversation with one another. Along with residents receiving physical therapy services, facility staff have an exercise period for residents with several equipment items offered daily during afternoons.

Toxins are stored in a locked cabinet in the facility garage and under kitchen sinks. During in the tour LPA observed two bottles of bleach located in separate restroom cabinets to be accessible to residents (photos taken). Items were immediately secured. There was a supply of hygiene products and paper products available for resident use. All residents bedrooms have lighting & appropriate furnishings. LPA conducted a sample review of staff training and found that all staff have current CPR and 1st Aid training on file.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643
VISIT DATE: 11/23/2022
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Upon observation of resident exit doors, LPA found that one auditory alarm in resident bedroom to be inoperable. In addition, LPA found a damaged door handle lock leading resident bedroom into the garage containing cleaning supplies and other items that could pose danger if accessible.

Infection Control
Facility has submitted an Infection Control Plan for review. Posters are located at the facility entrance, common areas and restrooms indicating COVID protocols and mitigation. Facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors, clients and staff. Staff and clients are also screened on a daily basis for temperatures and symptoms.

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.

LPA requested the following documents be sent to CCL by COB 11/30/2022:

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 InsuranceI
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/23/2022 02:44 PM - It Cannot Be Edited


Created By: Dominic Tobola On 11/23/2022 at 01:52 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: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

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 from observations of 2 bottles of bleach, and garage contaning additional potentially dangerous substances accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2022
Plan of Correction
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Licensee failed to ensure cleaning supplies and toxic substances were stored inaccessible to residents in care with dementia. Licensee immediately locked the substances in designated cabinets. In addition, Licensee is to ensure garage is kept secured and submit a LIC9098 Proof of Corrections form to CCLD by POC due date 11/24/2022.
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 Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/23/2022 02:44 PM - It Cannot Be Edited


Created By: Dominic Tobola On 11/23/2022 at 01:52 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: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

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 6 auditory alarms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2022
Plan of Correction
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Licensee failed to ensure all auditory alarms installed at faciltiy exits were in operating order. Licensee agrees to repair the 1 non-functioning auditory alarm and submit a LIC9098 Proof of Corrections for to CCLD by POC due date 11/30/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022


LIC809 (FAS) - (06/04)
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