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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 12/07/2022
Date Signed: 12/08/2022 10:45:28 AM

Document Has Been Signed on 12/08/2022 10:45 AM - 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: 5DATE:
12/07/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Renato YamatTIME COMPLETED:
02:22 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Case Management visit regarding an increase of capacity request by this facility. LPA met with, facility manager, Renato Yamat and toured this facility. There are currently 5 residents in care, with one receiving Hospice services. Community Care licensing (CCL) received a fire clearance approval from the Vallejo Fire department on 11/22/2022 for a total of 7 Non-ambulatory residents. This facility is now licensed for a total of 7 residents, with a hospice waiver to allow 6 residents on Hospice services and no approval for bedridden residents/rooms.

LPA toured facility and grounds, which were observed 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.


Exit interview conducted with Renato Yamat. No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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