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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 11/17/2022
Date Signed: 11/18/2022 09:17:47 AM

Document Has Been Signed on 11/18/2022 09:17 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 ARAGONFACILITY NUMBER:
486803945
ADMINISTRATOR:YAMAT, RENATOFACILITY TYPE:
740
ADDRESS:124 ARAGON COURTTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Michelle JangarTIME COMPLETED:
05:11 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Case Management - Health and Safety check of this facility.
LPA received information the facility home, may be in foreclosure status.

LPA toured the home and all resident rooms.
There are currently 5 residents living in the home with two staff providing care and supervision. The home was observed clean and at a comfortable temperature. LPA met with Administrator, Michelle Jangar (MJ) who explained the facility home is in good standing and is not in foreclosure status. Community Care Licensing (CCL) verified with the County assessor and Tax Treasury office and there are no current Liens on this property. This facility has a current lease agreement in file from the property owner. MJ reported they are always in communication with the property owner and expressed the information CCL received regarding the foreclosure is incorrect and will provide proof to LPA A. Canela by tomorrow 11/18/2022.

LPA observed the refrigerator has plenty of food, and the pantry is well stocked.

LPA will follow up on 11/18/2022 with facility, regarding the information that was requested.

No citations issued or observed.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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