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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801969
Report Date: 03/18/2025
Date Signed: 03/18/2025 12:36:09 PM

Document Has Been Signed on 03/18/2025 12:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:PRIMETIME CARE, LLCFACILITY NUMBER:
486801969
ADMINISTRATOR/
DIRECTOR:		SY,THELMAFACILITY TYPE:
740
ADDRESS:570 QUARTZ LANETELEPHONE:
(707) 310-3633
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 4CENSUS: 4DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Thelma Sy, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
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At approximately 9:35 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Administrator Thelma Sy and Licensee Danilo Sy. Primtime Care, LLC is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for four (4) non-ambulatory Residents. Upon arrival, LPA was informed that there were four (4) residents in care. During the inspection all residents were away at day programs. At approximately 9:50 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

At approximately 10:00 AM, LPA toured the facility with Administrator Sy. All exits were clear and unobstructed. The facility's fire extinguisher was last serviced and tagged on 6/12/2024. The Vallejo Fire Department's last inspection was on 7/26/2024. Food supply was sufficient. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 1/22/2025. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational.

Continued on 809-C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PRIMETIME CARE, LLC
FACILITY NUMBER: 486801969
VISIT DATE: 03/18/2025
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...Continued from 809

At approximately 10:35 AM, LPA reviewed four (4) resident files. Four (4) of four (4) resident files were found to be well organized and thorough with all required documentation. LPA reviewed three (3) staff files. All staff files were found to be well organized with all required documentation including First Aid and CPR certification. One (1) staff member had incomplete training documentation. A Technical Advisory is being issued for the incomplete training documentation. LPA spot checked Medication for two (2) residents. LPA observed all medications to be centrally stored, secure and with proper documentation. Resident’s monies for personal and incidental (P&I) items were audited and found to exceed the values listed on the LIC 400 Affidavit Regarding Resident Cash Resources. This deficiency will be cited.

Thelma Sy’s Administrator Certification 7006452740 is current with an expiration date of 10/25/2026.

LPA requested the following documents be submitted to Community Care Licensing by 4/18/2025:



LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Proof of Liability Insurance

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D, Plan of Corrections, LIC 9102 Technical Advisory and Appeal Rights discussed and provided to Director Licensee Danilo Sy. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 12:36 PM - It Cannot Be Edited


Created By: Robert Frank On 03/18/2025 at 11:59 AM
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: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(a)(b)(c)(d)
Title 22, Division 6
Chapter 1
Article 03. Application Procedures
80025
Bonding
(a)The licensee shall submit an affidavit, on a form provided by the licensing agency, stating whether he/she safeguards or will safeguard cash resources of clients and the maximum amount of cash resources to be safeguarded for all clients or each client in any month.
(b)All licensees, other than governmental entities, who are entrusted to care for and control clients' cash resources shall file or have on file with the licensing agency, a bond issued by a surety company to the State of California as principal.
(c)The amount of the bond shall be according to the following schedule:
AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED
$750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000
Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond.
(d)The licensee shall submit a new affidavit and bond to the licensing agency prior to the licensee safeguarding amounts of clients' cash resources in excess of the current bond.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review the licensee did not comply with the section cited above in that the total resident cash on hand was $4871.82 which exceed the current affidavit amount of $1000.00, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2025
Plan of Correction
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Licensee will submit to Community Care Licensing an updated LIC 400 Affidavit Regarding Resident Cash Resources and an updated LIC 402 Surety Bond by the POC Due Date of 4/18/2025.

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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Robert Frank
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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