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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801969
Report Date: 02/03/2023
Date Signed: 02/03/2023 02:45:12 PM

Document Has Been Signed on 02/03/2023 02:45 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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Andes Vilaluz, Lead StaffTIME COMPLETED:
03:00 PM
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On 2/3/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Andes Vilaluz. The Licensee, Thelma Sy was contacted and notified of the visit. The facility currently provides care for 4 clients all of which were present at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the kitchen was found to be last charged on 6/8/2022 at the time of the visit. Smoke and carbon monoxide detectors were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. The facility follows appropriate dietary measures based on client medical orders. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinet located in the garage and under the kitchen sink found to be secured. Sharps were observed to be kept locked in a designated drawer located in the kitchen. There was a supply of hygiene products and paper products available and kept in client individual bedrooms. Facility provides additional hygiene product to clients when requested and located in hallway closet. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets located in the hallway and found to be secured. Clients were observed to be in their respective bedrooms watching movies and in the kitchen with staff preparing lunch. Upon interviews, LPA found that clients appear to be comfortable interact well with staff.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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: PRIMETIME CARE, LLC
FACILITY NUMBER: 486801969
VISIT DATE: 02/03/2023
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Licensee, Thelma Sy's Administrator Certification 6021330740 expires on 10/25/2024.

LPA was notified that Lead Staff, Andes Vilaluz is currently in the process of becoming the new Administrator for the facility. LPA reviewed CCLD Administrator Certification check and found that Andes Vilaluz's certification 6065602740 was received as of 10/24/2022 and pending for completion.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 2/17/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC809 (FAS) - (06/04)
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