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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801175
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:14:11 PM

Document Has Been Signed on 03/20/2025 02:14 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:BERT LILLEEN CARE HOMEFACILITY NUMBER:
486801175
ADMINISTRATOR/
DIRECTOR:		EILEEN SADDIFACILITY TYPE:
740
ADDRESS:967 ZEPHYR LANETELEPHONE:
(707) 451-2042
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 2DATE:
03/20/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Lilia Saddi, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management -- annual continuation visit to review resident files, staff files, medications, and medication logs, and met with Lilia Saddi, Licensee.

At approximately 10:15 AM, LPA conducted file review. Four (4) staff and two (2) resident files were reviewed and LPA observed the following: Four (4) staff files were observed to have the required documentation per Title 22 regulations. However, LPA observed 3 of 4 staff files missing valid proof of completed required training, and 1 of 4 staff files were observed missing valid proof of the required first aid certification, (see LIC809Ds). LPA reviewed two (2) of two (2) resident files which were each observed to contain the required documents per regulation. However, LPA observed one (1) resident's file missing proof of negative TB results, (see, LIC809D).

Licensee states that the facility and residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. Medications and medication records were inspected and observed maintained in compliance with regulation. However, LPA advised Licensee on best practices for ensuring the medication logs accurately reflect medication start dates. Licensee conveyed understanding and agreed to bring the facility into compliance. Facility does not handle P&I.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or 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.

Exit interview conducted with Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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 03/20/2025 02:14 PM - It Cannot Be Edited


Created By: Julie Florio On 03/20/2025 at 01:54 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: BERT LILLEEN CARE HOME
FACILITY NUMBER: 486801175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring facility maintains proof of the required first aid training in each staff record which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Licensee agrees to submit proof of first aid training for each staff member to CCL by POC due date 4/11/2025.
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring facility maintains proof of negative TB results for each resident in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee agrees to submit proof of negative TB results for R1 to CCL by POC due date 4/18/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/20/2025 02:14 PM - It Cannot Be Edited


Created By: Julie Florio On 03/20/2025 at 02:07 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: BERT LILLEEN CARE HOME
FACILITY NUMBER: 486801175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(c)
Personnel Records 87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring facility maintains valid proof of completion of the required training hours for each staff member which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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4
Licensee to submit proof of completed training hours for each staff member to CCL by POC due date of 4/18/2025.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2025


LIC809 (FAS) - (06/04)
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