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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801175
Report Date: 11/03/2022
Date Signed: 11/03/2022 04:22:09 PM

Document Has Been Signed on 11/03/2022 04:22 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:BERT LILLEEN CARE HOMEFACILITY NUMBER:
486801175
ADMINISTRATOR:EILEEN SADDIFACILITY TYPE:
740
ADDRESS:967 ZEPHYR LANETELEPHONE:
(707) 451-2042
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 6CENSUS: 4DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Eileen SaddiTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Katrina Walters arrived unannounced to conduct a Required 1-Year Inspection and was greeted by staff. The Administrator and Licensee arrived later Eileen Saddi. The inspection is focused on the Infection Control procedures and practices of this facility.

At primary entrance LPA observed temperature logs and visitor sign-in sheet. Facility has at least a 30 day supply of N-95 mask, disposable gowns, COVID test and hand sanitizer were available for visitors. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan and Infection Control Plan was submitted and available for review. LPA toured the facility with staff and Administrator and made the following observations: LPA observed that both the bathroom and kitchen were sanitary and in good repair. There was hand soap and paper towels for clients use. All exits were unobstructed. Fire extinguisher was charged and serviced 01/10/2022. Smoke and carbon monoxide detector appeared to be operational. Hot Water temperature measured at 120.3 which was within regulation at 105-120 F.
LPA requested the following updated forms to be submitted to Community Care Licensing by 11/21/2022:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents/clients
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
**No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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