486801089-8-31-2023-21-AS-DTOA-CV8PKT-20230831112341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486801089
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:23:46 AM

Document Has Been Signed on 08/31/2023 11:23 AM - 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:	PRIMETIME BOARD & CARE HOME		FACILITY NUMBER:	486801089
ADMINISTRATOR:	SY, DANILO B.		FACILITY TYPE:	740
ADDRESS:	107 QUARTZ LANE		TELEPHONE:	(707) 644-0634
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	4	CENSUS: 1	DATE:	08/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Danilo & Thelma Sy, Licensee		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	8/31/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Licensee, Danilo & Thelma Sy. The facility is single story building licensed for 4 non-ambulatory residents. The facility currently provides care for 1 resident, who is not receiving hospice services or has diagnosis of dementia. The resident is non-conserved and receiving consumer services under North Bay Regional Center. The resident was attending day program at the time of visit. LPA continued with a tour of the facility with Licensee, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 7/2/2023. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room and found to be secured. There was a supply of hygiene products and paper products available for resident. All resident bedrooms have lighting & appropriate furnishings. Water was measured at faucets accessible to residents and was within regulation. Medications located in dinning area were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Store Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for resident R1 and found all items including Physician's Report and Individual Program Plan to be updated. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exits located in the side yard to be clear and unobstructed. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PRIMETIME BOARD & CARE HOME	FACILITY NUMBER: 486801089
	VISIT DATE: 08/31/2023

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Licensees' Danilo Sy's Administrator Certification 6024440740 is valid until 10/25/2024 & Thelma Sy's Administrator Certification 6021330740 is valid until 2/20/2025.

LPA requested the following documents be sent to CCL by COB 9/31/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Proof of ownership or lease/rental agreement

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC809 (FAS) - (06/04)

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