486803980-8-1-2023-21-AS-ACAA-CUB3FM-20230801181258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 08/01/2023
Date Signed: 08/01/2023 06:13:48 PM

Document Has Been Signed on 08/01/2023 06:13 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:	TENNESSEE CARE LLC		FACILITY NUMBER:	486803980
ADMINISTRATOR:	SY, MARK JAYSON		FACILITY TYPE:	740
ADDRESS:	3141 TENNESSEE ST.		TELEPHONE:	(707) 980-1098
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	4	CENSUS: 3	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Jayson Sy, Licensee/Administrator		TIME COMPLETED:	04:17 PM

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	Licensing Program Analyst (LPA), Araceli Canela arrived at Tennessee Care, LLC unannounced for the purpose of conducting a Required-1 year inspection. LPA met with care staff, Engel Carino and Jayson Sy, Licensee/Administrator arrived a few minutes later. This facility is licensed for 4 non-ambulatory residents, no approval for bed ridden and a Hospice Waiver for 2 of the residents. LPA toured the home and found the home to be clean, organized, at a comfortable temperature with all exits free from obstruction. There are a total of four bedrooms, 2 bathrooms, living room, dining room, kitchen and garage. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the front room was observed charged and serviced July 10, 2023. Fire drill was conducted by the facility and documented on 5/15/2023. There are auditory alerts on exit doors which were tested and functional. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in a locked cabinets in the kitchen. There is adequate space and furniture on the patio for outdoor activities. Fire place stove is observed with a screen/gate. There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. There is a locked cabinet that stores residents' medications. Resident and staff files are located and locked in cabinet. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 4/28/2025. Resident files were reviewed and found complete and organized. Administrators certificate for Jayson Sy #6042012740 expires 9/19/2024. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: TENNESSEE CARE LLC	FACILITY NUMBER: 486803980
	VISIT DATE: 08/01/2023

NARRATIVE

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Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 8/30/2023:

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-

No citations issued during todays inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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