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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801089
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:51:47 AM

Document Has Been Signed on 08/03/2022 11:51 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 HOMEFACILITY NUMBER:
486801089
ADMINISTRATOR:SY, DANILO B.FACILITY TYPE:
740
ADDRESS:107 QUARTZ LANETELEPHONE:
(707) 644-0634
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 2DATE:
08/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Thelma SyTIME COMPLETED:
12:00 PM
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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 Licensee, Thelma Sy (TS).The facility currently provides care for two residents, one of which was at day program and one of which was present at the time of inspection. Neither residents were reported to have a diagnosis of dementia.

LPA arrived at the facility was greeted by staff Ida Villaluz and had temperature checked and logged. LPA continued with a tour of the facility with facility staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Licensee, Thelma Sy arrived at a later time during the inspection. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 6/8/2022 at the time of the visit. Smoke and carbon monoxide detectors 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 sufficient for the two residents in care. 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. However, LPA found one storage cabinet to be unlocked with toxins potentially accessible to residents. Cabinet was immediately locked and discussed with staff. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings.

Infection Control:
Facility has submitted an Infection Control Plan for review. All staff and residents have been vaccinated with no reported or observed symptoms. Facility staff are screened on a daily basis and residents are screened based on observation and changes of symptoms or condition. 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.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2022
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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