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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801089
Report Date: 06/26/2024
Date Signed: 06/26/2024 09:57:30 AM

Document Has Been Signed on 06/26/2024 09:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PRIMETIME BOARD & CARE HOMEFACILITY NUMBER:
486801089
ADMINISTRATOR/
DIRECTOR:
SY, DANILO B.FACILITY TYPE:
740
ADDRESS:107 QUARTZ LANETELEPHONE:
(707) 310-3633
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 0DATE:
06/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Thelma Daezsy,LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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At approximately 8:45 AM, Licensing Program Analyst (LPA) Stefanie Mutialu conducted an unannounced Annual Required inspection to this facility and was greeted by Administrator/Licensee Thelma Daezsy. At approximately 9:00 AM, LPA and Administrator/Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. Toxins are secure and not accessible to clients. Medication willl be centrally stored and secure in a cabinet. There is a sufficient supply of linens on hand for client use.

No clients admitted at this time awaiting North Bay Regional for client placement. No current personnel files to be reviewed. Two out of two water faucets were inspected and found to be within regulation. Water temperature measured within regulation between 109 and110 degrees F at faucets accessible to clients.

Seven out of seven smoke detectors and one out of one carbon monoxide detector were inspected and found to to be in working order. One out of one fire extinguisher was fully charged.

Administrator's Certificate for Danilo Sy certificate #7034479740 is current with an expiration date as of 02/21/2025.

No deficiencies were observed in the areas inspected. No citations issued during today’s visit.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC308- Designation of Responsibility
Updated Liability Insurance
Surety Bond
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2024
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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