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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803643
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:46:24 PM

Document Has Been Signed on 12/10/2024 02:46 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:SABILE HOUSE OF CAREFACILITY NUMBER:
486803643
ADMINISTRATOR/
DIRECTOR:		SABILE, ROSAUROFACILITY TYPE:
740
ADDRESS:388 VALLE VISTA AVENUETELEPHONE:
(707) 315-1941
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 3DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:29 AM
MET WITH:Rosauro Sabile (Licensee)TIME VISIT/
INSPECTION COMPLETED:
03:01 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Stevenson arrived unannounced to conduct an annual required – 1 yr. visit of the facility and met with Licensee/Administrator Rosauro Sabile. There are residents receiving hospice services and diagnostic of dementia. Required postings were observed. At approximate 11:30am LPA/Licensee observed that there are annual fees outstanding in the amount of $495. Licensee was provided with Pin number to make an online payment.

LPAs/Licensee toured the facility at 11:45 AM, the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices and all auditory devices were working properly. Fire Extinguisher was found to be last charged on January 2024. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Last disaster drills have not been conducted quarterly with the last one being conducted on 4/10/24. Hot water temperature measured 110.3 and 110 which is within Title 22 regulation. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Toxins are stored in a locked cabinet in the kitchen. There was a supply of cleaners, hygiene products and paper products available for residents. All bedrooms have lighting & appropriate furnishings. Contact information was reviewed. The facility does not handle cash resources. The bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. However, one out of three sinks in the main bathroom located in the hallway had a sign of "out of order". Also, LPAs/Licensee observed that garbage cans located in the bathrooms did not have tight-fitting covers in the containers. Licensee agreed to repair needed items. LPAs/Licensee observed some deck boards needed to be replaced. Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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Document Has Been Signed on 12/10/2024 02:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/10/2024 at 02:21 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of three sinks in the main bathroom located in the hallway had a sign of "out of order". Also, garbage cans located in the bathrooms did not have tight-fitting covers in the containers, some deck boards needed to be replaced which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee agreed to perform repair needed and will submit pictures of repaired items by POC due date to clear the citation.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff do not have a current CPR/1st aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee will ensure that staff received CPR/1st aid training and will submit LIC9098 self-certification form to CCL by POC due date to clear the citation.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/10/2024 02:46 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 12/10/2024 at 02:21 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not conducting a disaster drill within the last quarter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee agreed to perform a disaster drill and will send LIC9098 self-certification form to CCL to clear the citation by POC due date.
Type B
Section Cited
CCR
87156(b)(1)(F)
Licensing Fees. In addition to fee set forth in subdivision (a), the department shall charge the following fees: A late fee that represents an additional 50 percent of the established annual fee when any licensee fails to pay the annual licensing fee on or before the due date as indicated by postmark on the payment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not paying their licensing fees in the amount of $495 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee agreed to submit payment to CCL by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


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: SABILE HOUSE OF CARE
FACILITY NUMBER: 486803643
VISIT DATE: 12/10/2024
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Continued from LIC809...

LPAs initiated file review at 12:00pm. Three resident's files and three staff files were reviewed. All residents have current medical assessments, but one out of three resident's pre-appraisal assessment have not been completed (technical violation was issued). One out three staff do not have additional 20 hours of training complete. Two out of three staff needs to update their 1st aid/CPR certificates. Administrator certificate for Administrator Rosauro Sabile #7011753740 expired on 5/2024. LPAs have reviewed the Department's certification unit list and found that the administrator is listed in the pending list. Medication and medication records were reviewed.



Licensee agreed to submit updates of the following documents by 12/20/24: LIC 308 Designated of facility responsibility, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan – if changes, copy of Certificate of Liability Insurance and proof of control of property.

Deficiencies 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. Exit interview was conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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