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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 11/21/2022
Date Signed: 11/22/2022 02:58:24 PM

Document Has Been Signed on 11/22/2022 02:58 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 ARAGONFACILITY NUMBER:
486803945
ADMINISTRATOR:YAMAT, RENATOFACILITY TYPE:
740
ADDRESS:124 ARAGON COURTTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
11/21/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Warren Delfin, LicenseeTIME COMPLETED:
01:41 PM
NARRATIVE
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An informal meeting was conducted today, by the Santa Rosa Regional Office via Microsoft . Present in the meeting were, Regional Manager, Carla Martinez- Nutti, Licensing Program Manager, Kimberley Mota, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Araceli Canela and Licensee, Warren Delfin.

The purpose of the informal office meeting was to discuss concerns that have been identified by the Licensing Agency regarding information received of this facility being in Foreclosure status.

The following was discussed during the office meeting:
Facility to notify all residents and/or their responsible parties and the local Ombudsman regarding the foreclosure of this property by 11/22/2022.

Community Care Licensing (CCL) requested copy of letter issued by the licensees attorney to the lender of this home. Licensee to also include a copy of the financial plan for this licensee and records discussed during this meeting.

The department will conduct a Solvency Audit on all five (5) of the licensee's facilities.

Health & Safety Code 1569.686 was cited today. Licensee must notify within 2 business days the Department, the state long term ombudsman, all residents, and their representatives of financial distress. Licensee to ensure the services of residents in their facility are not affected by home owner/Licensee default. Civil Penalty assessed for $100 per day, maximum of 20 days. Total assessed during todays office meeting is $2,000.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was emailed to licensee to obtain signatures.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2022
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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Document Has Been Signed on 11/22/2022 02:58 PM - It Cannot Be Edited


Created By: Araceli Canela On 11/21/2022 at 02:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PROVIDENCE HOME OF ARAGON
FACILITY NUMBER: 486803945

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
HSC
1569.686(a)

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1569.6869a) Licensee notification of specified events; department initiation of compliance plan, noncompliance conference, or other appropriate action; penalties; exception. (a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence, and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event:
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Licensee agrees to issue letters and notify all residents and/Ombudsman by 11/22/2022. Licensee to provide copies of letters to CCL by 1or their responsible parties, Local 1/22/2022 Attention LPA: Araceli Canela
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This requirement was not met as evidenced BY: Based on today's meeting with licensee, the facility failed to notify CCL, Local Ombudsman & resident or their responsible parties as required. This is an immediate risk to the Health and Safety of residents in care.
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A civil Penalty was assessed today for a total of $2,000. for HSC1569.686 violation

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kimberley Mota
LICENSING EVALUATOR NAME:Araceli Canela
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022


LIC809 (FAS) - (06/04)
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