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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 01/26/2023
Date Signed: 01/27/2023 09:51:18 AM

Document Has Been Signed on 01/27/2023 09:51 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:
01/26/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Michelle JangarTIME COMPLETED:
01:25 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 and Licensee are in communication regarding the facility ownership 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 and records for resident R2, plan of care and medical records. LPA also went over resident R1 who had recently sustained a fall while R1 was getting up from their commode. Facility notified LPA by phone and with an incident report within the required time and sent R1 to the hospital. R1 returned the same day. LPA observed and talked to R1, who said he is doing well.


Facility understands they will need to continue to provide any updates or changes regarding the ownership 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: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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