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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 07/20/2021
Date Signed: 07/20/2021 01:03:03 PM

Document Has Been Signed on 07/20/2021 01:03 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:PROVIDENCE HOME OF VALLEJOFACILITY NUMBER:
486803850
ADMINISTRATOR:JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:1391 OAKWOOD AVETELEPHONE:
(707) 805-0784
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Michelle Jangar and Staff Member Mylagrace AlcaldeTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Providence Home of Vallejo for the purpose of conducting an Required-1 year inspection. LPA was greeted at the door by Staff Member, Mylagrace Alcalde and was granted access into the facility.

LPA toured the facility with Staff Member, Mylagrace Alcalde. The home appears clean and is at comfortable temperature with all exits free of any obstructions and sufficient lighting for residents in care. The upstairs of the home is used for staff only, and cleaning products are stored in one bathroom that is locked. The smoke alarm system and carbon monoxide detector were inspected and operational during the visit. Food was stored properly and the refrigerator was observed clean. The food supply was adequate between inside and garage refrigerators, freezers and cabinets. Hot water was checked and within regulation of 105 to 120 degrees F. The bathrooms have grab bars for clients use. Resident medications are secured and locked inaccessible to residents in care. Fire extinguisher was observed to be last inspected in September 2020.

In addition, LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills conducted on March 2021. Facility has PPE supply stored in the kitchen cabinet. Staff have had all PPE training required on file and still working towards acquiring N-95 fit testing.

No deficiencies cited during today's Required 1- Year inspection. LPA obtained a copy of the updated liability insurance. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Michelle Jangar.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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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