486803890-2-28-2024-21-AS-ACAA-D2W23A-20240228160200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 02/26/2024
Date Signed: 02/28/2024 04:02:56 PM

Document Has Been Signed on 02/28/2024 04:02 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 HILLVIEW		FACILITY NUMBER:	486803890
ADMINISTRATOR:	JANGAR, MICHELLE		FACILITY TYPE:	740
ADDRESS:	141 HILLVIEW DR		TELEPHONE:	(650) 740-8043
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 4	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Michelle Jangar, Administrator		TIME COMPLETED:	05:04 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Michelle Jangar. There are currently 4 residents in care, one 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.. LPA toured facility and grounds and observed all required signs posted in common areas. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguishers were fully charged, and have proof of service on 1/6/2024. Smoke detectors and carbon monoxide detectors are operational. Fire drills are conducted and the last one was documented on 1/29/2024. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars. The shed in the back yard is for storage of equipment only. Resident and staff files are located and locked in staff office. LPA reviewed resident files and 2 out of 4 residents required an updated medical assessment. Staff files were reviewed and had no proof of required annual training and/or training was not documented to show the date of training or hours that were completed. LPA went over required documentation, training certificates or materials to be kept in file per employee. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

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 HILLVIEW	FACILITY NUMBER: 486803890
	VISIT DATE: 02/26/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator certificate for Michelle Jangar # 6008305740 expired 10/25/2023 and Administrator explained they had submitted all paperwork and are still waiting for a copy of their new Administrator certificate.

The side yard gate on the left of the home and the sliding door and door in the living room and the sliding door in the master bedroom require attention as all doors are a little harder to open and close. Facility was asked to service doors so that they open easily.

LPA discussed Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the below documents to LPA by 3/25/2024.

· 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)
Copy of Liability Insurance-
Copy of Administrator Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/28/2024 04:02 PM - It Cannot Be Edited

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 HILLVIEW	FACILITY NUMBER: 486803890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays record review with Administrator, the licensee did not comply with the section cited above in 2 of 3 staff files reviewed did not have proof of the required annual training and/or the training was not documented to show the date and time of hours trained for 2 out of 3 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will stay in compliance, and proof of staff training to LPA Canela by 3/13/2024

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on todays resident record review with Administrator S1. Resident R1 and R2 did not have a current medical assessment in file, the licensee did not comply with the section cited above in 2 out of 4 residents did not have proof of a current medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Facility to send in written plan on how they will stay in compliance, and proof of current medical assessment for resident R1 and R2 to LPA Canela by 3/27/2024

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3