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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 02/27/2023
Date Signed: 02/27/2023 07:58:31 PM

Document Has Been Signed on 02/27/2023 07:58 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: 5DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Michelle JangarTIME COMPLETED:
03:21 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Michelle Jangar. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 5 residents in care, two 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. There is a total of 6 residents bedrooms available.

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 states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation and Infection Control plan was submitted to the department. Caregivers have completed PPE.

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. Fire Extinguisher was found to be charged and serviced 2/16/2023.

This facility submitted a requested for increase of capacity to 7 residents. Due to concerns and review of a current financial report of this facilities applicant. The request for increase of capacity to seven(7) residents is denied at this time. Facility may apply for an increase at a later time.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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 HILLVIEW
FACILITY NUMBER: 486803890
VISIT DATE: 02/27/2023
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LPA went over daily activities being available for residents.

LPA went over the following updated forms to be submitted to LPA A Canela by 3/27/2023.

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of Liability Insurance
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.







Exit interview conducted with, Administrator, Michelle Jangar.

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

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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