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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801089
Report Date: 08/09/2021
Date Signed: 08/09/2021 03:07:46 PM

Document Has Been Signed on 08/09/2021 03:07 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PRIMETIME BOARD & CARE HOMEFACILITY NUMBER:
486801089
ADMINISTRATOR:SY, DANILO B.FACILITY TYPE:
740
ADDRESS:107 QUARTZ LANETELEPHONE:
(707) 644-0634
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 4DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Jayson Sy, AdministratorTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Jayson Sy (JS).The facility currently provides care for four (4) residents some of which with a diagnosis of dementia.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; 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 weas found to be last charged on 3/10/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in designated storage closets in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured at 109.5 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents.

During the tour LPA observed two prescription medications in resident bathroom accessible to residents with dementia. Administrator and care staff immediately removed all medications from resident bathroom and placed in a secured medication cabinet (photos taken). In addition, LPA also observed an inoperable auditory alarm in R1's bedroom sliding door exit. Administrator immediately replaced the auditory alarm battery and LPA confirmed the alarm functions properly.

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and residents have been vaccinated with no reported or observed symptoms. Staff conduct surveillance testing weekly with 25% of staff every seven days. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened based on a daily basis.

Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
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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Document Has Been Signed on 08/09/2021 03:07 PM - It Cannot Be Edited


Created By: Dominic Tobola On 08/09/2021 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PRIMETIME BOARD & CARE HOME
FACILITY NUMBER: 486801089

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in 2 out of 2 prescription medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2021
Plan of Correction
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Administrator failed to ensure presciption medications were kept inaccessible to residents with dementia. Administrator immediately removed medications and placed them in a secured cabinet. Administrator agrees to review regulation 87705 and submit a LIC9098 Proof of Correction Form to CCL by POC date 8/10/2021 ensuring that the facility will be in compliance moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2021


LIC809 (FAS) - (06/04)
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