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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 02/25/2022
Date Signed: 02/25/2022 08:12:42 PM

Document Has Been Signed on 02/25/2022 08:12 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 HILLVIEWFACILITY NUMBER:
486803890
ADMINISTRATOR:JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:141 HILLVIEW DRTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 3DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Renato Yamat jr.TIME COMPLETED:
11:48 AM
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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 Jr. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 3 residents in care, none 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 COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was submitted to the department on 8/24/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged and serviced 1/11/2022.

Facility staff to get N95 fit tested.

Exit interview conducted with Renato Yamat. No deficiencies cited during this inspection. Report will be emailed due to printer issues
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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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