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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:53:42 AM

Document Has Been Signed on 08/16/2024 11:53 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/
DIRECTOR:		JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:1391 OAKWOOD AVETELEPHONE:
(707) 805-0784
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Renato "June" Yamat, Asst. AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jill Nakagawa 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.

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. The facility was found to be clean and residents appeared well cared for; clean and appropriately dressed. Medications and sharps were locked and inaccessible to residents. The outside of facility was free of debris and provided shaded seating areas for residents and visitors to enjoy.

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 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.

No citations issued
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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