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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803031
Report Date: 04/08/2022
Date Signed: 04/08/2022 05:07:07 PM

Document Has Been Signed on 04/08/2022 05:07 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:JEN-N-LEEN BOARD AND CARE HOMEFACILITY NUMBER:
486803031
ADMINISTRATOR:SADDI, JENNIFERFACILITY TYPE:
740
ADDRESS:2355 BURGUNDY WAYTELEPHONE:
(707) 429-8465
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 6CENSUS: 2DATE:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Jennifer Saddi, Licensee/AdministratorTIME COMPLETED:
05:16 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Jennifer Saddi, Licensee/Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
LPA conducted a walk-through of the facility with Administrator. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors. LPA was screened for COVID-19 symptoms and temperature was taken. The facility carbon monoxide detector and 9 smoke detectors were tested and observed operational. Administrator has valid CPR/first aid certification. Fire extinguisher was charged and serviced 02/11/2022.
The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with residents. Staff clean and disinfect the facility throughout the day. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.

The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.
All staff wore masks during this visit.

LPA discussed the following requirements with Administrator:
· Document staff and resident daily temperatures
· N-95 Fit testing (Cal/OSHA Requirement) for staff
· Staff training on the following COVID-19 related subjects: infection prevention, symptoms, transmission and PPE use.
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: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
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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