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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 06/03/2026
Date Signed: 06/03/2026 01:25:59 PM

Document Has Been Signed on 06/03/2026 01:25 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 VALLEJOFACILITY NUMBER:
486803850
ADMINISTRATOR/
DIRECTOR:		JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:1391 OAKWOOD AVETELEPHONE:
(707) 805-0784
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 5DATE:
06/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Michelle Jangar (Administrator)TIME VISIT/
INSPECTION COMPLETED:
01:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Cuadra arrived unannounced to conduct a Required -1 Year visit, and met with administrator, Michelle Jangar. Annual fees are current. Required postings observed.

LPA/administrator 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 bedroom, 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. LPA/administrator observed that there were no snacks been provided to residents between meals. LPA had a conversation with the administrator regarding the importance of providing snacks to residents in care. LPA observed the facility has supply of fruits and vegetables (technical violation issued). The facility has emergency supplies, including food and water to meet requirements of the 72-hour shelter in place. Resident and staff files are located in the dining room and locked in cabinet. All medications were all locked and inaccessible to residents in care. No activities were conducted during LPA's visit (technical violation issued). LPA had a conversation with the administrator about the importance of activities. Facility's smoke and carbon monoxide detectors were operational. Bathrooms have non-skid surfaces and grab bars at the toilet and shower areas. Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2026
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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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)
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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 VALLEJO
FACILITY NUMBER: 486803850
VISIT DATE: 06/03/2026
NARRATIVE
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Continued from LIC809... Fire extinguishers last charged and serviced on June 2026. Exit doors have auditory alarms to alert staff. Hot water measured 104.2 degrees F, which is not within regulation of 105 to 120 degrees F at faucets used by residents in care (technical violation issued).

- At 9:45 AM, LPA conducted a file review of three staff and five residents. All staff have current 1st aid/CPR certificates updated and completed all required training hours. There are residents receiving hospice care services within the approved hospice waiver. Two out of five residents (R3 & R4) do not have a current care plan and residents (R1 and R2) care plans are incomplete because administrator did not include reposition, history of skin breakdown and incontinence care as specified in their physician's reports (LIC602) for staff to be able to provide assistance and supervision of these needs. Based on interviews with staff (S1 & S2) they were aware of these care needs and they are assisting residents with adequate care (technical violation issued). Residents have half bed rails doctor's order on file. Administrator agreed to update care plans accordingly. Administrator Michelle Jangar, administrator certificate 7002269740 expires on 10/25/2027. Medications and medication records were reviewed. At approximately 10:00am, LPA/administrator reviewed residents (R1 & R4) records that revealed that they both has a diagnosis of diabetes, their physician report (LIC602) determines that they are not able to administer own injections or perform own glucose testing. Administrator acknowledges that R1 & R4 have a diagnosis of diabetes, but confirmed that they do not have a glucometer and accessories to daily monitor residents' glucose levels.

At approximately at 11:45am LPA/administrator observed that last fire drill was conducted January 21, 2026, the facility has not been conducting drills quarterly.



Administrator agrees to submit updates of the following documents by not later than 6/17/26:
(LIC 500) Personnel Report, (LIC 308) Designated facility responsibility & copy of liability Insurance.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, and the Health and Safety Code. Appeal Rights Given. Exit interview conducted with Administrator 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: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/03/2026 01:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/03/2026 at 12:58 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 VALLEJO
FACILITY NUMBER: 486803850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/administrator interviews & file review the licensee failed to ensure that two out of two residents (R1 & R4) are diabetic were retained at the facility while not able to perform a glucose testing as per physician's report, but the facility did not ensure R1’s & R2's glucose levels were monitored, which poses an immediate risk to the health and safety of residents in care.
POC Due Date: 06/04/2026
Plan of Correction
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The Administrator agrees to ensure blood glucose testing is performed by an appropriately skilled medical professional or contact R1’s & R2's physician for current blood glucose order and submit proof that they have reached out to the physician's and ensure a skilled medical professional is performing the test by POC due date.
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: 06/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/03/2026 01:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/03/2026 at 12:58 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 VALLEJO
FACILITY NUMBER: 486803850

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents (R3 & R4) do not have a current care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2026
Plan of Correction
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Administrator agrees to review all residents care plans and updated them accordingly including care needs indicated in their physician's report. Administrator will submit self certification form (LIC9098) ensuring to the department that care plans were updated as stated per regulation by POC due date 06/17/26.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on l[(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/17/2026
Plan of Correction
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Administrator agrees to conduct a quarterly disaster drill for each shift. Administrator will submit self certification form (LIC9098) ensuring to the department that disaster drill was performed for each shift as stated per regulation by POC due date 06/17/26.
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: 06/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2026


LIC809 (FAS) - (06/04)
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