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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801969
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:33:14 AM

Document Has Been Signed on 03/27/2024 11:33 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 CARE, LLCFACILITY NUMBER:
486801969
ADMINISTRATOR:SY,THELMAFACILITY TYPE:
740
ADDRESS:570 QUARTZ LANETELEPHONE:
(707) 310-3633
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 3DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:TIME COMPLETED:
11:40 AM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Caregiver/Administrator Andres Villaluz. Licensee/Administrator Danilo Sy arrived during visit.

This facility has a fire clearance for four non-ambulatory. There are three resident rooms: two private and one shared. The shared resident room has a private full bathroom. All three resident rooms have an exit to the outside. There is one full common bathroom. There is one staff room. The backyard has a covered area.

The following was observed during today's visit:
-facility meets the seven day non-perishable and two day perishable food supply.
-two of three resident records were reviewed
-all staff files were reviewed
-the backyard has furniture and two appliances that Caregiver stated is going to be picked up soon. The furniture and appliances are stacked and placed in ways that do not impede any walkways in the back nor do they pose a hazard. LPA was informed the items are being picked up this Friday.

The following shall be updated and submitted to Community Care Licensing Division by April 19, 2024:
-a copy of the current liability insurance
-LIC 308 designation of administrative responsibility
-LIC 500 personnel report or staff schedule


No deficiencies were observed.
No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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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