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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803890
Report Date: 08/16/2024
Date Signed: 08/16/2024 11:17:07 AM

Document Has Been Signed on 08/16/2024 11:17 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/
DIRECTOR:		JANGAR, MICHELLEFACILITY TYPE:
740
ADDRESS:141 HILLVIEW DRTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY: 6CENSUS: 4DATE:
08/16/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Renato "June" Yamat, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Case Management-Legal/Non-compliance Inspection and met with Renato "June" Yamat, covering Administrator.

LPA conducted a walk-through of the facility, and it was found at a comfortable temperature with all exits free from obstruction. The residents were clean and appropriately dressed and several were up engaged in social interactions.
The refrigerator was observed with plenty of food that was stored properly and in good condition. Doors were properly alarmed. Resident rooms furnished as required. Bathrooms clean and sanitary with required non-skid mats and grab bars. Medications and sharps locked and secured. There are currently 4 resident in the home. There were 2 care staff on duty at the time of inspection.
This facility was placed on non-compliance on May 1, 2023 for a one-year term.

LPA reminded facility of the below agreement of 5/1/2023 between Community Care Licensing (CCL) and Facility.
  • Facility agreed to ensure proper bookkeeping and having adequate Finance staff and not commingle funds between all five (5) licensed facilities. Facility to ensure food costs are related to the resident census per facility.


No citations issued
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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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