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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 12/15/2021
Date Signed: 12/16/2021 02:46:08 PM

Document Has Been Signed on 12/16/2021 02:46 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, 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:
12/15/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Mark Jayson SyTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Araceli Canela conducted an unannounced post-licensing inspection on 12/15/2021. LPA met with Administrator Mark Jayson Sy. There are no residents in care, LPA discussed Emergency Disaster Drills to be conducted every 3 months.
During today’s visit LPA observed the following items:
· COVID-19 postings and screening station at entrance. LPA was screened prior to entering.
· Lockable separate cabinets for toxin and knives.
· All exits were unobstructed
· 7 hardwired combination smoke and 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 of 2 bathrooms.
· Fire Extinguisher charged
· Required furnishings in all 4 resident bedrooms
· Administrator Certification (expires 09/19/2022); Required postings (Personal Rights, Emergency plan/numbers, CCLD complaint poster, Emergency Disaster Plan, Client personal rights and visitor policy).
· Water temperature was tested & within regulation of 105 to 120 degrees F
· Auditory devices in doors, observed operational
· Resident's medication will be centrally stored and locked.
· Food supplies were within regulation
· Facility records reviewed, staff have CPR and 1st Aid certifications.

No deficiencies cited during today's inspection
Exit interview conducted with Administrator, Mark Jayson Sy and a copy of this report will be emailed
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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