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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804164
Report Date: 06/06/2024
Date Signed: 06/06/2024 12:32:09 PM

Document Has Been Signed on 06/06/2024 12:32 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:JEN-N-LEEN BOARD & CAREFACILITY NUMBER:
486804164
ADMINISTRATOR/
DIRECTOR:		SADDI, JENNIFERFACILITY TYPE:
740
ADDRESS:196 BRIGHTON CIRTELEPHONE:
(707) 372-7352
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Jennifer Saddi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA met with Administrator/Licensee, Jennifer Saddi. At approximately 9:45AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in locked cabinets. Water temperature measured within regulation between 111 and 117 degrees F at five out of five faucets accessible to residents. One of one fire extinguisher inspected was charged. Ten out of ten smoke detectors were found to be in working order. Three out of three carbon Monoxide detectors were present and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

LPA observed two of five residents in the living room watching television and interacting with residents dog. LPA observed staff interacting and checking on residents often. LPA observed two of five residents in their rooms. One resident was resting and watching television in their room. The other client was relaxing in their room awaiting to be picked up by their spouse for a doctor's appointment. One of five residents is in the hospital after experiencing a stroke and will be returning upon discharge from the hospital. LPA observed residents happy, active, and engaging. Each room reflected residents preferences and the common areas was reflective of a home atmosphere/environment to include holiday, Fourth Of July decorations. One of five residents owns a cat and dog which provides pet therapy for all residents per Administrator. Per resident's comments, they are well taken care of, the food very good, they are bathed daily, the place is kept clean, and the staff are wonderful, work very hard and ensure each resident's needs are met.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JEN-N-LEEN BOARD & CARE
FACILITY NUMBER: 486804164
VISIT DATE: 06/06/2024
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At approximately 11:00AM, LPA reviewed four of five residents records and three of three Staff records, which were all found to be well organized, thorough and contained the required documentation. First aid and CPR certification were current in staff files. Medication records are thorough and contained physician's orders. Administrator's Certificate was expired as of 05/2024. Administrator has completed CU and submitted payment but still awaiting recertification certificate. Administrator to submit proof of payment to CCL.

At approximately 11:40 AM, LPA reviewed the facility emergency disaster plan with staff. Facility has emergency flash lights during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. LPA advised Administrator Emergency Disaster Plan needs to be updated with non-local evacuation site outside of Vacaville. Facility has supplies enough to operate for more than 72 hours in an emergency. LPA advised Administrator per regulation need to have water supply to last 72 hours for five residents in case of emergency.F acility conducted and documented a disaster drill on 04/24/2024.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC610 - Disaster Plan (updated)
Register of Residents
Proof of Administrator Certificate Fee payment

The following documents were submitted during inspection visit:


Evidence of Liability Insurance
Fire Clearance/Inspection

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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