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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803850
Report Date: 06/26/2023
Date Signed: 06/27/2023 01:34:46 PM


Document Has Been Signed on 06/27/2023 01:34 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:JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:1391 OAKWOOD AVETELEPHONE:
(707) 805-0784
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
06/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:39 PM
MET WITH:Renato Yamat, Assistant AdministratorTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, assistant Administrator, Renato Yamat. There are currently 5 residents in care, with one of the residents receiving Hospice services. This facility is licensed for a total of 6 residents, with a hospice waiver to allow all 6 residents on Hospice services and no approval for bedridden residents/rooms.

LPA toured facility and grounds and observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. This facility is a two story home and all resident bedroom are located in the first level and staff occupy the second level. LPA observed gates at the bottom of both stairs. Residents have push button system to alert staff for assistance. Fire Extinguisher was found to be last charged and serviced on February 16, 2023. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in resident bathrooms measured at 108 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen and garage and food is stored properly. Medications were centrally stored and locked. Medication Assessment Records (MARS) were reviewed during the inspection and were found to be appropriate. Cleaning products and other toxins are locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all resident bedrooms was conducted, and bedrooms inspected have lighting and appropriate furnishing.

Administrator certificate for Michelle Jangar #6008305740 expires 10/25/2023. Staff have the required training. Resident files were reviewed and in compliance.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023
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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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: 06/26/2023
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Assistant Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 7/21/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Liability Insurance
Copy of current Lease Agreement


No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2023
LIC809 (FAS) - (06/04)
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