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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 11/18/2024
Date Signed: 11/19/2024 09:09:04 AM

Document Has Been Signed on 11/19/2024 09:09 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/
DIRECTOR:
YAMAT, RENATOFACILITY TYPE:
740
ADDRESS:124 ARAGON COURTTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
11/18/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:28 PM
MET WITH:Renato Yamat, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:20 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 in their rooms. 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 3 resident in the home. There were 3 care staff on duty at the time of inspection.

Facility is in communication with residents medical providers and trying to schedule a visit for residents to get the flu or Covid vaccination.


No citations issued during todays inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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