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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 02/10/2025
Date Signed: 02/10/2025 03:12:17 PM

Document Has Been Signed on 02/10/2025 03:12 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/
DIRECTOR:		JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:141 HILLVIEW DRTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
02/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:48 AM
MET WITH:Brigida Perez & Evelyn Espinoza, caregiversTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with caregivers, Brigida Perez & Eveyn Espinoza. Administrator, Michelle Jangar was available by phone. There are currently 4 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..

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 2/6/2025. Smoke detectors and carbon monoxide detectors are operational. Fire drills are conducted and the last one was documented on 1/10/2025. Water temperature in the resident bathroom was tested and found to be fluctuating up and down over 120 and under 120 degrees. Staff adjusted thermostat and agreed to do daily water temperatures for a week, document and send to LPA. 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. Staff files were reviewed and had proof of training and CPR/1st aid expire on 5/15/2025.

Continue report see LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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 HILLVIEW
FACILITY NUMBER: 486803890
VISIT DATE: 02/10/2025
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Administrator certificate for Michelle Jangar # 6008305740 expires 10/25/2025.

LPA spent time talking with residents. LPA requested update on residents vaccinations for the flu and Covid-19 as residents wanted to know when they would receive the vaccinations.

Licensee/Administrator to submit the below documents to LPA by 3/05/2025.



· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report-
· 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



No deficiencies cited during todays inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025
LIC809 (FAS) - (06/04)
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