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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801175
Report Date: 01/30/2025
Date Signed: 01/30/2025 04:14:40 PM

Document Has Been Signed on 01/30/2025 04:14 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: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
01/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Lilia Saddi, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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At approximately 2:30 PM, Licensing Program Analysts (LPAs) Julie Florio and Star Stevenson arrived unannounced to conduct a required 1-year annual inspection and were greeted by facility Staff. Licensee was contacted via telephone and arrived at approximately 2:45 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with three (3) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for two (2), and is approved for 2 non-ambulatory residents. Facility currently has two residents on Hospice.

At approximately 3:00 PM, LPAs initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed unlocked in two instances. Licensee removed the items immediately and secured them in the locked laundry room. Licensee agrees to ensure all items which could pose a risk to residents in care are secured at all times to remain compliance with regulation. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed an activity schedule and books, puzzles, and movies for residents. Facility does not have an internet access device designated for resident use, but Licensee agrees to purchase one immediately. Facility has internet service available to residents in care and the telephone was tested an operational during inspection.

Facility's fire extinguisher was observed charged and was last serviced 02/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 01/2025.

Continued on LIC809-C...
Bethany MoellersTELEPHONE: (707) 588-5040
Julie FlorioTELEPHONE: (707) 588-5026
DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BERT LILLEEN CARE HOME
FACILITY NUMBER: 486801175
VISIT DATE: 01/30/2025
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Continued from LIC809C...

LPAs observed the facility's infection control plan, several first aid kits, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 01/2025.

Licensee stated they would like to change the Administrator. LPA discussed what needs to be submitted to CCL for this change. LPAs will return at a later date to complete the annual inspection. LPAs will review resident files, staff files, and medications and medication logs during that visit. Facility does not manage P&I.

Required Change of Administrator Documents:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Statement signed by Licensee requesting Change of Administrator

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC500 - Personnel Report (updated)
  • Copy of New Liability Insurance Policy

No deficiencies were cited during inspection.

Exit interview conducted with Licensee whose signature on form confirms receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025
LIC809 (FAS) - (06/04)
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