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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 07/14/2022
Date Signed: 07/18/2022 10:03:38 AM

Document Has Been Signed on 07/18/2022 10:03 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 2DATE:
07/14/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Jayson SyTIME COMPLETED:
11:29 AM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Jayson Sy and care staff Edson Arceo. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 2 residents in care. This facility is licensed for 6 ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 1/3/2022. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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: TENNESSEE CARE LLC
FACILITY NUMBER: 486803980
VISIT DATE: 07/14/2022
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LPA requested the following updated records to be submitted to Community Care Licensing by 8/10/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 402 Surety Bond
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents

Exit interview conducted with Jayson Sy, Licensee/Administrator.
No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC809 (FAS) - (06/04)
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