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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803643
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:09:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/13/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230313123922
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: 3DATE:
07/28/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Consolacion Espra, Lead CaregiverTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Neglect/Lack of Care and Supervision resulted in resident sustaining severe injuries
INVESTIGATION FINDINGS:
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On 7/28/2023, Licensing Program Analyst (LPA), Tobola arrived unannounced for the purpose of delivering complaint findings and was greeted by Lead Caregiver Staff, Consolacion Espra. Licensee, Sabile Rosauro was contacted but unable to attend visit. This department has investigated the allegations by taking tours of the facility, conducting interviews of staff, residents, and outside parties, reviewing resident records during the course of the investigation.

Complaint alleges Neglect/Lack of Care and Supervision resulted in resident sustaining severe injuries. Based on a review of incident reports and medical records it was found that resident (R1) had been sent to Sutter Solano for medical attention on 3/10/2023. Medical records indicate that R1 had been admitted to the Sutter Solano Medical Center on 3/10/2023 after facility observed R1 to be bedbound for two days (3/8/2023-3/9/2023) without energy. Upon admission to the medical center, R1 was assessed and observed to have a total of 17 wounds, including multiple pressure ulcers, a stage one pressure injury to R1's right hip and an unstageable severe traumatic injury to R1's right wrist/hand resulting in amputation of R1's right hand. Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20230313123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/28/2023
NARRATIVE
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Interviews with facility Licensee and caregiver staff (S1 & S2) state that these individuals did not observe or were aware of any bruises, sores or injuries on R1's body. Although R1 does not require bed reposition based on R1's physician's report, staff were aware of R1's behavior of sitting on their hands and R1's right had appeared red on 3/9/2023. This resulted in severe ischemia potentially due to R1 not being monitored and R1's hands not moved or off-loaded until the following morning on 3/10/2023. Staff did not provide proper assessments and supervision regarding R1's multiple pressure wounds that were observed by emergency ambulance staff and medical center staff upon R1's admission to Sutter Solano Medical Center.

Interviews with Sutter Solano Medical physician and registered nurse staff (I1 & I2) indicated that R1's wounds to the right hip and wrist/hand was potentially caused from cut blood flow circulation for a "prolonged time" and "at least several hours" without staff providing proper supervision, assessments and observation of R1's wounds and overall health condition while in the facility.


Today, 7/28/2023 the Department An immediate civil penalty is being assessed today in the amount of $500 for a violation that resulted in the sickness or injury of a resident in care.
The licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230313123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2023
Section Cited
CCR
87466
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87466: Observation of the Resident. Licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of mental ability or a physical health condition are observed, Licensee shall
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Administrator agrees to schedule training with an approved outside vendor for all care staff with for all staff regarding observation of a residents. Plan for training to be submitted to CCL by POC due date. Proof of training including trainer, topics covered, date and time spent and attendees to be submitted by 8/11/ 2023.

Additionally, Administrator will provide company protocol outlining how residents are observed for changes and how those changes are reported to management. Writtten plan to be submitted by POC date 7/29/2023.
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ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person, if any. Requirement is not met as evidenced by: Based on Department investigation, resident (R1) sustained mulitple pressure injuries and severe injury resulting in amputation which poses an immediate health and safety risk to residents.
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“An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in bodily injury or illness of a person in care. As a result of client’s injury, the violation warrants a civil penalty assessment based on Health and Safety Code 1569.49(f). At this time, the civil penalty assessment is under review.”
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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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3