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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 12/27/2022
Date Signed: 12/27/2022 02:33:58 PM

Document Has Been Signed on 12/27/2022 02:33 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:
12/27/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Michelle JangarTIME COMPLETED:
11:10 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 has been reaching out to the facility for an update regarding the facilities 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 observed the refrigerator has plenty of food, and the pantry is well stocked.

LPA met with Administrator, Michelle Jangar and requested an update to be provided to LPA by 12/28/2022, regarding the facility status or any information received that may affect the residents living at this facility.


Facility understands they will need to continue to provide any updates or changes regarding the financial status of this facility or anything that may affect the Health & Safety and well being of all the residents living at this facility.


No citations issued during this visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2022
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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