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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 02/05/2025
Date Signed: 02/05/2025 08:20:24 PM

Document Has Been Signed on 02/05/2025 08:20 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, 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: 6DATE:
02/05/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:09 PM
MET WITH:Renato "June" YamatTIME VISIT/
INSPECTION COMPLETED:
03:55 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 Administrator, Renato "June" Yamat.

LPA conducted a walk-through of the facility, and it was found at a comfortable temperature with all exits free from obstruction. The residents were observed to be comfortable, resting or engaged in activities. The refrigerator was observed with plenty of food that was stored properly and in good condition. Doors were properly alarmed. Resident rooms furnished as required. Bathrooms clean and sanitary with required non-skid mats and grab bars. Medications and sharps locked and secured.

There are currently 6 resident in the home. There were 3 care staff on duty at the time of inspection.


No citations issued during visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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