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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 03/11/2026
Date Signed: 03/11/2026 01:51:02 PM

Document Has Been Signed on 03/11/2026 01:51 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/
DIRECTOR:		YAMAT, RENATOFACILITY TYPE:
740
ADDRESS:124 ARAGON COURTTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 6DATE:
03/11/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:26 AM
MET WITH:Michelle Jangar (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct a Required -1 Year visit, and met with staff. Licensee, Michelle Jangar arrived later and disclosed that Administrator Renato Yamat is no longer working at the facility. According to the Licensee, there was a notification submitted to the Department via email to report the change of Administrator.

LPA/staff toured the facility common areas, hallways, residents rooms, kitchen and bathrooms observed had sufficient lighting. Residents rooms are furnished per regulation. The facility was a comfortable temperature. Passageways were free of obstructions. Facility has a sufficient supply of cleaners, hygiene items and paper products. A call button is located in each bathroom, LPA tested the call system in resident's rooms and staff response time was under three minutes. A tour and inspection of the kitchen area were found to be clean and sanitary. The kitchen was observed to have a sufficient supply of perishable and non-perishable food. Prepared and left over foods were covered and labeled. The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. The shed in the back yard is for storage of equipment only. Resident and staff files are located and locked in cabinet. All medications were all locked and inaccessible to residents in care. Required postings were observed. Annual fees are current. No activities were conducted during LPA's visit (technical violation issued). LPA had a conversation with the Licensee about the importance of activities. There were eight garbage cans located in bathrooms and resident's rooms do not have a lid/cover (technical violation issued). Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
Document Has Been Signed on 03/11/2026 01:51 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/11/2026 at 12:53 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in all fire extinguishers were expired as February 2025 and two out of five residents are bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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Licensee will follow up on getting fire extinguishers charged. Also, the Licensee will contact updated physician's report for two residents (R1 and R2) to get updated ambulatory status corrected on LIC602s. The facility will submit self-certification as proof that both items were corrected to CCL by POC due date.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the temperature reading of hot water facets not used by residents, the kitchen sink facet reading was 135.5 and 124 in the bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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Licensee agrees to place warning signs for faucets delivering water 125 or above. To clear this violation, Licensee will submit photo proof of each faucet identified in this report with a warning sign placed near the facet to warn the user of the hot water temperature. Photos to be submitted to CCL by POC date by 3/12/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 03/11/2026 01:51 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/11/2026 at 12:53 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in three out of ten staff individuals (I1, I2 & I3) were fingerprint cleared, but their fingerprints have not been transferred and associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2026
Plan of Correction
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LPA confirmed I1, I2 & I3 has cleared finger prints. Licensee agrees to email/fax required documents to CCL to associate individuals who two of them were working and present at the facility at the time of inspection to clear the citation. ***Civil Penalty assessed in the amount of $1500 for each staff not associated to this facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 03/11/2026 01:51 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/11/2026 at 12:53 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in shared bathroom between room#5 and 6 shower head is leaking. There was a bucket full of water holding water coming off from shower head which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee shall submit self-certification (LIC9098) they have read fixed showerhead. Self-certification shall be submitted to CCLD by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee records review and interview, the licensee failed to have at least staff member who has CPR and 1st Aid training on duty at all times. Facility has 2 out of 3 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Licensee to submit self-certification form (LIC9098) ensuring that staff have current CPR trained per regulation by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 03/11/2026 01:51 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/11/2026 at 12:53 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interviews and record review, the licensee did not comply with the section cited above in that 3 out of 3 staff did not have Heatth Screens including TB tes on file, which poses a potential health, safety or personal rights risk to persons in care. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee to ensure staff have health screening including TB test done and shall submit self-certification (LIC9098) they have obtained health screening for all three staff including TB test. Self-certification shall be submitted to CCLD by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of three staff there was no proof of staff having obtained required annual direct care staff training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee to ensure that staff S3 obtain required annual training for direct care staff. Licensee shall submit self-certification (LIC9098) they have obtained required annual training hours. Self-certification shall be submitted to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 03/11/2026 01:51 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/11/2026 at 12:53 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: 03/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in five out of five residents do not have bed rails order on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2026
Plan of Correction
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Licensee to ensure physician orders are on file for the use of postural supports. Licensee will submit self-certification form ensuring that all residents have bed rails orders on file to clear the citation by POC due date 3/25/26.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2026


LIC809 (FAS) - (06/04)
Page: 7 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ARAGON
FACILITY NUMBER: 486803945
VISIT DATE: 03/11/2026
NARRATIVE
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Continued from LIC809...
At approximately 9:45am Shared bathroom between room#5 and 6 shower head is leaking. There was a bucket full of water holding water coming off from shower head.

At approximate 10:00am LPA/Licensee observed hot water measured 130.6 and 129.6 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care.

At approximately at 10:15am LPA/Licensee observed fire extinguishers were observed to be last charged on 2/2025.

Facility's smoke and carbon monoxide detectors were operational. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. Exit doors have auditory alarms to alert staff. The last fire drill was conducted 01/20/26.

- At 10:30 AM, LPA conducted a file review of three staff and five residents. LPA observed three out of six staff individuals (I1, I2 & I3) were fingerprint cleared, but their fingerprints have not been transferred and associated to the facility. LPA informed Licensee that staff (I1, I2 & I3) are not associated to facility and should never be working and providing care to residents prior to a criminal record clearance transfer. Civil penalties are being assessed in the amount of $100 per person per day for a total amount of $1500 for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance transfer and association. Three out of three staff (S1, S2 & S3) do not have a health screening form on file including their TB test. Two out of three staff (S2 & S3) do not have current 1st aid or CPR certificates updated. One out of three staff (S3) have not completed all required training hours. There are residents receiving hospice care services within the approved hospice waiver. However, based on deficiencies found during today's visit, Licensee was informed that a review of current hospice waiver of six residents will be reviewed. All residents' care plans are updated. Medical assessments are current and included a description of any known behavioral expression. Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
Page: 11 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 ARAGON
FACILITY NUMBER: 486803945
VISIT DATE: 03/11/2026
NARRATIVE
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Continued from LIC809C...At approximately 11:00am, LPA/Licensee reviewed the facility approved fire clearance dated 11/30/2020 by the Vallejo Fire Department for six non-ambulatory residents of which one may be bedridden in bedroom #2 only. Resident R3 is occupying room #2 which is the only room approved as bedridden room. However, during records review two other residents (R1 & R2) out five residents have a bedridden status and are occupying room #3 and room #6 respectively, which are not cleared by the Fire Department as bedridden rooms. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/Licensee discussed the issue with R1 and R2 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance. According to the Licensee, R1 and R2 are not bedridden and they will obtain an updated physician's report (LIC602). During the visit, LPA spoke with R1 and R2 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. Five out of five residents (R1, R2, R3, R4 & R5) does not have half bed rails order on file. However, it appears like R5 does not need bed rails. Licensee Michelle Jangar, administrator certificate 7002269740 expires on 10/25/2027. Medications and medication records were reviewed.

Documentation Needed for Change of Administrator:



- LIC 200 indicating change of administrator. - LIC 501 Personnel Record.
- LIC 500 Personnel Report (indicating amount of hours to be spent at the facility).
- LIC 308 Designation of facility responsibility. - LIC 503 Health Screening Report.
- Copy of Administrator's certificate. - Detailed employment/education history.

Licensee agrees to submit updates of the following documents by not later than 3/25/26:
Copy of liability Insurance, emergency disaster plan (LIC610E).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, and the Health and Safety Code. ***Civil penalties in the amount of $1500.00 is being assessed due to staff not being associated to facility. Appeal Rights Given. Exit interview conducted with Licensee and copy of this report was given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC809 (FAS) - (06/04)
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