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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804164
Report Date: 06/06/2023
Date Signed: 06/06/2023 11:18:33 AM

Document Has Been Signed on 06/06/2023 11:18 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JEN-N-LEEN BOARD & CAREFACILITY NUMBER:
486804164
ADMINISTRATOR:SADDI, JENNIFER D.FACILITY TYPE:
740
ADDRESS:196 BRIGHTON CIRTELEPHONE:
(707) 372-7352
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 0DATE:
06/06/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Jennifer SaddiTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived announced at Jen-N-Leen Board & Care for the purpose of conducting a Pre-Licensing Inspection due to a Change of Location (CHOL). LPA was greeted at the door by Administrator, Jennifer Saddi, and was granted access into the facility. The facility is approved for 6 non-ambulatory residents with 0 bedridden and 0 ambulatory. Administrator presented the LPA with the Administrators Certificate for Residential Care for the Elderly (Standard Certificate #6014581740 with an expiration of 05/22/2024).

LPA and Administrator toured the facility. LPA observed the facility to be clean, safe and sanitary with all exits free from obstruction. However, upon initial entry into the facility, LPA observed a fountain. During questioning, LPA learned that the fountain will not be in use and water will not be dispensed out of the fountain. LPA and Administrator observed a cover on the fountain which makes the fountain non-operational. Fire Extinguishers were found to be last charged on February 2023. All smoke detectors and carbon monoxide detectors were tested and found to be operational at the time of the Pre-Licensing inspection. Hot water temperature measured at 90.1 degrees in 3 of 3 residents bathrooms and is not within regulation (See LIC 9102-Technical Advisory). LPA educated the Administrator on the importance of having hot water that is within acceptable range of 105-120 degrees. Sample food menu was observed on the refrigerator. LPA observed sufficient perishable and non-perishable foods located in the refrigerator and pantry. There was ample space for personal hygiene products, bedding and linens, utensils, dishes, and cook ware. Resident records, personnel records and medications will be locked and in separate cabinets which are inaccessible to residents in care. Hazardous items and toxins are kept locked in the garage and inaccessible to residents in care. Facility has a first aid kit which was inspected and found to be appropriate during the Pre-Licensing inspection. There is an outdoor space for activities with a shaded area for residents in care.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023
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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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: JEN-N-LEEN BOARD & CARE
FACILITY NUMBER: 486804164
VISIT DATE: 06/06/2023
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During the Pre-Licensing inspection, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. All staff will be trained in the Emergency Disaster and PPE training. Emergency Disaster plan was discussed with the Administrator. During the review of the Emergency Disaster Plan, LPA observed No Transportation Providers were listed on the Emergency Disaster Plan, no temporary Shelter Locations listed on the Emergency Disaster Plan and no utility shut-offs were listed on the Emergency Disaster Plan (See LIC9102-Technical Advisories). Administrator disclosed that she will update the Emergency Disaster Plan and will forward to the Centralized Applications Bureau (CAB) Analyst.

LPA was advised that the facility is in the process of obtaining a Emergency Generator.

Component III was waived due to already being licensed.

Exit interview was conducted, and a copy of this report was given to the Administrator. LPA will forward this report to the assigned Application Analyst in our Department; The Application Analyst will notify the Applicant of the status of the application.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC809 (FAS) - (06/04)
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