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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801969
Report Date: 03/04/2022
Date Signed: 03/04/2022 02:23:41 PM

Document Has Been Signed on 03/04/2022 02:23 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:PRIMETIME CARE, LLCFACILITY NUMBER:
486801969
ADMINISTRATOR:SY,THELMAFACILITY TYPE:
740
ADDRESS:570 QUARTZ LANETELEPHONE:
(707) 310-3633
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 4DATE:
03/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Danilo Sy, LicenseeTIME COMPLETED:
02:30 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 was greeted by Licensee, Danilo Sy (DS). Administrator, Jayson Sy (JS) was contacted and arrived during the visit. The facility currently provides care for four (4) residents none 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 was found to be last charged on 5/10/2021 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 securely stored under kitchen and bathroom sinks and 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 between 108.5 and 110.8 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents.

During the tour LPA found that two (2) staff (S1 & S2) had fingerprint background clearance but were not properly associated to the facility. LPA has copies of Background Check Clearance documentation for S1 & S2. Administrator to immediately contact appropriate Department agency and associate staff to facility.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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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 CARE, LLC
FACILITY NUMBER: 486801969
VISIT DATE: 03/04/2022
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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. 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 on a daily basis.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Civil Penalties are also being assessed in the amount of $200.00 due to two (2) staff not properly associated to the facility. Today's assessment of $100.00 for each staff is for violation of Title 22 Regulation # 88735(e)(2).

Danilo Sy's Administrator Certificate 6024440740 is valid until 2/20/2023
Jayson Sy's Administrator Certificate 6042012740 is valid until 9/19/2022

Exit interview conducted with facility Licensee, whose signature on this document confirms receipt.
A copy of the signed report was emailed to Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
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Document Has Been Signed on 03/04/2022 02:23 PM - It Cannot Be Edited


Created By: Dominic Tobola On 03/04/2022 at 01:40 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PRIMETIME CARE, LLC
FACILITY NUMBER: 486801969

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff which poses/posed a potential health, safety or personal rights risk to persons in care. Two (2) staff had received background fingerprint clearance but not properly associated to the facility.
POC Due Date: 03/05/2022
Plan of Correction
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Administrator agrees to associate 2 out of 2 staff (S1 & S2) to the facility and submit proof of association to CCL. In addition, Administrator to provide updated LIC500 Personnel Report. Items are to be submitted to CCL by POC due date 3/5/2022.
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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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