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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803980
Report Date: 08/14/2025
Date Signed: 08/14/2025 04:47:43 PM

Document Has Been Signed on 08/14/2025 04:47 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: 4DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Mark Sy, Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Hansen arrived at Tennessee Care, LLC unannounced for the purpose of conducting a Required-1 year inspection. LPA met with Jayson Sy, Licensee/Administrator.

This single story 4 bedroom facility is licensed for 4 non-ambulatory residents, with a Hospice Waiver for 2. LPA toured the building and grounds and found the home to be clean, organized, at a comfortable temperature with all exits free from obstruction. There are also, 2 bathrooms, living room, dining room, kitchen and garage. There was a 2 day supply of perishable and 7 day supply of non-perishable foods as per Title 22 regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Water temperature in the resident bathroom was found to be within appropriate range of 105-120 degrees F. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations. Cleaning products and knives are stored in key locked cabinets in the kitchen and locked cabinets in the garage. All bedrooms have lighting & appropriate furnishings per Title 22 regulations. Fire place, wood stove is observed with a screen/gate and licensee explained that it is not used.

A review of four resident & four staff records as well as two resident medications was conducted. LPA reviewed resident’s files at 8:45 AM on 8/14/2025 and learned that 4 of 4 residents have an updated reappraisal/needs & care plan, TB and physician’s assessments on file as required by Title 22 Regulation. Medications were centrally stored in locked closet in living room, overflow of medication in office cabinet.

Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/14/2025 04:47 PM - It Cannot Be Edited


Created By: Shannan Hansen On 08/14/2025 at 11:09 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TENNESSEE CARE LLC
FACILITY NUMBER: 486803980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, Staff S1 did not have a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee has agreed and schedueld staff S1 to obtain a health screening, including a TB test, and results. Licensee to submit copies of the documents by POC due 8/29/25 to LPA. If there are complications Licensee to contact LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


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: 08/14/2025
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Continued from LIC809

At approximately 10:45am a sample review of Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 9:30 AM on 8/14/2025 and learned that all facility staff present and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff at the facility have received additional training requirements. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. 1 (new staff) out of 4 staff files reviewed did not have health screening or TB test results (see LIC809D) Smoke detectors and carbon monoxide detectors were tested and operational. Fire extinguisher was observed charged & serviced July 8, 2025. Disaster drills are conducted quarterly with the last documented on 5/9/2025. Facility has a generator in case of power outage. Administrators certificate for Jayson Sy #6074468740 expires 12/15/2026.



Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 7/31/2025:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan (if changes)

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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