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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 10/21/2022
Date Signed: 10/21/2022 01:48:16 PM

Document Has Been Signed on 10/21/2022 01:48 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, 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: 3DATE:
10/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jayson Sy, AdministratorTIME COMPLETED:
02:00 PM
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On 10/21/2022 Licensing Program Analyst, LPA Tobola conducted an unannounced Case Management visit for the purpose of inspecting facility after decreased change of capacity. Facility was previously licensed for 6 residents, 3 of which may be non-ambulatory. With the updated request the facility capacity would reflect as 4 residents, 4 of which may be non-ambulatory.

LPA conducted a walkthrough of the facility and all resident bedrooms. This facility has been approved and licensed for 4 residents that may be non-ambulatory, and no approval for bedridden. A new license to reflect the changes will be sent to the facility.

LPA received updated copy of facility sketch indicating changes.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2022
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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