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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 09/13/2024
Date Signed: 09/13/2024 04:40:42 PM

Document Has Been Signed on 09/13/2024 04:40 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/
DIRECTOR:		SY, MARK JAYSONFACILITY TYPE:
740
ADDRESS:3141 TENNESSEE ST.TELEPHONE:
(707) 980-1098
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 4CENSUS: 3DATE:
09/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:Mark Jayson Sy, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA), Araceli Canela arrived at Tennessee Care, LLC unannounced for the purpose of conducting a Required-1 year inspection. LPA met with Jayson Sy, Licensee/Administrator.

This facility is licensed for 4 non-ambulatory residents, no approval for bed ridden and a Hospice Waiver for 2 of the residents. LPA toured the home and found the home to be clean, organized, at a comfortable temperature with all exits free from obstruction. There are a total of four bedrooms, 2 bathrooms, living room, dining room, kitchen and garage. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher was observed charged & serviced July 10, 2024. Fire drill was conducted & documented on 5/26/2024. Water temperature in the resident bathroom was found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in key locked cabinets in the kitchen. Fire place, wood stove is observed with a screen/gate and licensee explained that it is not used.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 1/20/2025 & 4/28/2025. Resident files were found complete and organized. Administrators certificate for Jayson Sy #6042012740 expires 9/19/2024 and licensee submitted renewal paperwork.

Licensee/Administrator to submit the following documents for our file by 10/15/2024:· LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · LIC 9020 Register of Facility Residents Infection Control Plan of Operation (If changes) & Copy of Liability Insurance

No citations issued during todays inspection.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2024
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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