486803850-5-18-2026-21-AS-BMOS-DUMRT4-20260601131743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803850
Report Date: 05/18/2026
Date Signed: 05/18/2026 03:12:14 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2026 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20260508141452

FACILITY NAME:	PROVIDENCE HOME OF VALLEJO		FACILITY NUMBER:	486803850
ADMINISTRATOR:	JANGAR, MICHELLE		FACILITY TYPE:	740
ADDRESS:	1391 OAKWOOD AVE		TELEPHONE:	(707) 805-0784
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	05/18/2026
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Michelle Jangar (Administrator)		TIME COMPLETED:	03:27 PM

ALLEGATION(S):

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-Personal Rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra conducted an unannounced visit and met with Administrator Michelle Jangar. LPA came to the facility to investigate and deliver findings of above complaint allegation.

The Department received an allegation of Personal Rights. Per Reporting Party, resident (R1) they have been keeping constant communication, but on 5/8/26, they were unable to contact R1 with their cell phone, then they called the facility where they were able to connect with R1 and were told that facility staff took their phone away for unknown reason. According to Reporting Party, in the past, R1 contacted them telling them "hey come get me I need to escape a little bit from here". Also, R1 expressed that they are isolated in the home and that "no one speaks English". On 05/18/26, LPA conducted a 10-day visit, reviewed records, made observations, interviewed residents (R1, R2, R3 & R4) and staff (S1 & S2). Based on interviews conducted with residents (R1, R2, R3 & R4), it indicates that residents feel that their personal rights are respected providing information about their freedom and choice to receive/make phone calls or visitors at any time. Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20260508141452

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/18/2026

NARRATIVE

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Continued from LIC9099A...

R1 stated that they get assistance from all staff when needed including assisting them to place phone calls because they are learning to use their new device, but they did not provide any supportive information regarding staff not allowing them to use their phone. Interviews conducted by LPA with staff (S1 & S2) indicated that they are assisting residents when they need to make a phone call to anybody, they help by locating the contact name of the person that they want to call, then they leave the room to allow them to have privacy. Based on LPA's observations, residents who has a cellphone, the devices were in their possession at the time of visit and they were able to locate them. Also, LPA observed staff's interactions with residents where they were able to held a conversation with residents in care. Based on records review of the facility admission agreement page #13-14, item E regarding guest visits and communication, the facility visiting hours are between 10am- 6pm daily, offers telephone services as follow: “personal calls are accepted from 10am to 7pm, except urgent matters”. Based on records review, R1's physician report indicates that R1 doesn't have any cognitive challenges. Based on interviews, observations and records review, LPA is unable to determine if a violation of personal rights occurred at a prior date. A finding that the allegation of facility violating resident's personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC9099 (FAS) - (06/04)

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