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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 02/01/2024
Date Signed: 02/02/2024 11:52:09 AM

Document Has Been Signed on 02/02/2024 11:52 AM - 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: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: 3DATE:
02/01/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Renato "June" YamatTIME COMPLETED:
02:26 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Renato "June" Yamat, covering Administrator. LPA conducted a walk-through of the facility, and it was found at a comfortable temperature with all exits free from obstruction. This facility was placed on non-compliance on May 1, 2023 for a one-year term.

The refrigerator was observed with plenty of food that was stored properly and in good condition. There is an additional refrigerator with food in the garage.

LPA went over compliance plan and reminded facility of the below agreement of 5/1/2023 between Community Care Licensing (CCL) and Facility, Providence Home of Aragon.
  • Facility agreed to provide quarterly financial documents for the month of August/September/October 2023 by November 17,2023. Records for November/December 2023 and January of 2024 by February 16, 2024, and February/March/April 2024 by May 17, 2024.
  • Facility agreed to ensure proper bookkeeping and having adequate Finance staff and not commingle funds between all five (5) licensed facilities. Facility to ensure food costs are related to the resident census per facility.
  • LPA went over recent Hospice resident admitted (R1) in December 2023 and the facility notified Community Care Licensing (CCL) as required of new Hospice intake. R1 expired on 1/28/2024, and facility notified LPA as required and report is being completed and will be sent to CCL within the required time.

No citations issued
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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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