Routine inspection·August 14, 2025

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 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 & 1 st 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