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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803945
Report Date: 03/08/2024
Date Signed: 03/08/2024 03:30:38 PM


Document Has Been Signed on 03/08/2024 03:30 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 ARAGONFACILITY NUMBER:
486803945
ADMINISTRATOR:YAMAT, RENATOFACILITY TYPE:
740
ADDRESS:124 ARAGON COURTTELEPHONE:
(650) 740-8043
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 3DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Renato "June" Yamat, AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Renato "June" Yamat. There are currently 3 residents in care, none are 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 approval for one(1) bedridden resident. At this time there is one bedridden resident and they occupy the bedroom approved as bedridden by the fire department and Community Care Licensing (CCL).

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 1/8/2024. Smoke detectors and carbon monoxide detectors are operational. Fire drills are conducted and the last one was documented on 1/08/2024. Water temperature in the resident bathroom was tested at 117 degrees F. 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 cabinet. LPA reviewed resident and staff files and were found complete and organized. Staff have proof of CPR/1st aid training exp.5/11/2023


Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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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 ARAGON
FACILITY NUMBER: 486803945
VISIT DATE: 03/08/2024
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Administrator certificate for Renato "June" Yamat # 6054180740 expired 8/16/2023 and Administrator explained they have submitted all paperwork and are still waiting for a copy of their new Administrator certificate.

LPA discussed Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the below documents to LPA by 4/5/2024.



· 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

No citations issued during todays visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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