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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803031
Report Date: 03/21/2023
Date Signed: 03/21/2023 12:59:39 PM


Document Has Been Signed on 03/21/2023 12:59 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: 1DATE:
03/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jennifer Saddi, Licensee/AdministratorTIME COMPLETED:
01:12 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection. LPA met with Jennifer Saddi, Licensee/Administrator.
LPA toured the facility and observed all exits were unobstructed. Fire extinguisher was charged and serviced 02/23/2023. 8 smoke detectors & 1 carbon monoxide detector were tested & observed operational. LPA reviewed staff and resident files. Staff have cardiopulmonary resuscitation (CPR) training and first aid training completed. Administrator has completed N-95 respirator Fit testing (Cal/OSHA requirement). LPA observed resident medication to be centrally stored. Bedrooms were furnished per regulation. The facility was found to be clean and at a comfortable temperature. LPA observed hygiene supplies, hand soap and paper towels available in bathrooms. Food supply was within regulation. Administrator has updated the facility Infection Control Plan. All staff wore masks during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 04/21/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of liability insurance
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate

Exit interview conducted with Jennifer Saddi, Licensee/Administrator, whose signature on this document confirms receipt. *** No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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