Tennessee Care

Type of visit: Required - 1 Year

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 care staff, Engel Carino and Jayson Sy, Licensee/Administrator arrived a few minutes later. 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 located in the front room was observed charged and serviced July 10, 2023. Fire drill was conducted by the facility and documented on 5/15/2023. There are auditory alerts on exit doors which were tested and functional. Water temperature in the resident bathroom was tested and 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 a locked cabinets in the kitchen. There is adequate space and furniture on the patio for outdoor activities. Fire place stove is observed with a screen/gate. There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. There is a locked cabinet that stores residents' medications. Resident and staff files are located and locked in cabinet. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 4/28/2025. Resident files were reviewed and found complete and organized. Administrators certificate for Jayson Sy #6042012740 expires 9/19/2024. Continue report see LIC809-C Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Licensee/Administrator to submit the current following documents by 8/30/2023: · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources · 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.the state’s words, verbatim · CDSS document, Aug 1, 2023

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Oct 21, 2022

Type of visit: Required - 1 Year

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 and serviced July 14, 2022. Continue report see LIC809-C LPA previously requested the following updated records to be submitted to Community Care Licensing and were received. · 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 inspectionthe state’s words, verbatim · CDSS document, Aug 5, 2022

Type of visit: Annual/Random

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 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 inspectionthe state’s words, verbatim · CDSS document, Jul 14, 2022

Type of visit: Post Licensing

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 emailedthe state’s words, verbatim · CDSS document, Dec 15, 2021

Type of visit: Prelicensing

Licensing Program Analyst (LPA) A. Canela conducted a pre-licensing inspection and met with Applicant/Administrator Mark Jayson Sy. Fire clearance was approved by the Vallejo Fire Department on 8/9/2021 for a total of 6 residents, of which 3 are Non-ambulatory and 3 are Ambulatory. LPA successfully conducted a component III orientation with Mark Jayson Sy. LPA toured facility and observed: Facility is a one story home, in good repair and at a comfortable temperature. Hot water temperature checked between 107 and 108 degrees F in 2 out of 2 resident's faucets as required by Title 22 Regulations. The facility has a phone line designated for residents' use. Personnel and residents' records are stored at a locked kitchen cabinet. The home includes kitchen, dining area, 4 bedrooms, 2 bathrooms, living room, provider room/office and garage. Required posting for facility were observed, along with several Covid guidance posters. The facility has a table in front area by door with sign in sheet, hand sanitizer, thermometer and small garbage can. During today’s visit LPA observed the following items: · Lockable separate cabinets for medications, toxin, and knives. · All exits were unobstructed · 7 hardwired smoke detectors, 2 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 bathrooms. · Required furnishings in resident bedrooms · Fire Extinguisher charged and serviced 5/13/2021 · Administrator Certification for Mark Jayson Sy #6042012740 exp. 9/19/22 Mitigation Plan was received on 9/10/2021 and approved Pre-licensing is complete, no corrections needed and can proceed with licensure. Application Unit Analyst will notify applicant of application status.the state’s words, verbatim · CDSS document, Sep 14, 2021

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): NO Method: Telephone call with CAB COMP II Participants: MARK JAYSON DITAN SY & RACHEL ANN ARCEO SY Applicant/administrator Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1.Facility operation: License type, client/resident populations, and program 2.Staff qualifications and responsibilities 3.Applicant and Administrator qualifications 4.Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5.Grievances, Complaints, Community resources 6.Physical plant, food service 7.Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of property 8. Discussed the COVID-19 Mitigation Plan & PIN emailedthe state’s words, verbatim · CDSS document, Aug 17, 2021