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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 09/14/2021
Date Signed: 09/15/2021 09:53:29 AM

Document Has Been Signed on 09/15/2021 09:53 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:TENNESSEE CARE LLCFACILITY NUMBER:
486803980
ADMINISTRATOR:SY, MARK JAYSONFACILITY TYPE:
740
ADDRESS:3141 TENNESSEE ST.TELEPHONE:
(707) 980-1098
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 0DATE:
09/14/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mark Jayson SyTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) A. Canela conducted a pre-licensing inspection and met with Applicant/Administrator Mark Jayson Sy. Fire clearance was approved by the Vallejo Fire Department on 8/9/2021 for a total of 6 residents, of which 3 are Non-ambulatory and 3 are Ambulatory. LPA successfully conducted a component III orientation with Mark Jayson Sy.
LPA toured facility and observed: Facility is a one story home, in good repair and at a comfortable temperature. Hot water temperature checked between 107 and 108 degrees F in 2 out of 2 resident's faucets as required by Title 22 Regulations. The facility has a phone line designated for residents' use. Personnel and residents' records are stored at a locked kitchen cabinet.

The home includes kitchen, dining area, 4 bedrooms, 2 bathrooms, living room, provider room/office and garage. Required posting for facility were observed, along with several Covid guidance posters. The facility has a table in front area by door with sign in sheet, hand sanitizer, thermometer and small garbage can.

During today’s visit LPA observed the following items:
· Lockable separate cabinets for medications, toxin, and knives.
· All exits were unobstructed
· 7 hardwired smoke detectors, 2 carbon monoxide detectors which were tested and observed to be operational
· First Aid kit, night-lights, and flashlights for emergency lighting
· Supply of linens, paper products, and hygiene supplies available
· Grab bars and non-slip mats in 2 bathrooms.
· Required furnishings in resident bedrooms
· Fire Extinguisher charged and serviced 5/13/2021
· Administrator Certification for Mark Jayson Sy #6042012740 exp. 9/19/22

Mitigation Plan was received on 9/10/2021 and approved

Pre-licensing is complete, no corrections needed and can proceed with licensure. Application Unit Analyst will notify applicant of application status.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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