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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003989
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:56:59 AM


Document Has Been Signed on 02/07/2023 11:56 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:JOHNSON FAMILY CHILD CAREFACILITY NUMBER:
198003989
ADMINISTRATOR:JOHNSON, PAMELLA MAXINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 612-0904
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:14CENSUS: 1DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela Johnson & Stephen JohnsonTIME COMPLETED:
10:30 AM
NARRATIVE
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Case management inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua and Licensing Program Manager (LPM) Ana Chico. LPA met with licensee. The purpose of this inspection is to address the issues that were observed/occurred on 1/31/2023. On 1/31/2023, at around 8:37am, LPA Hua arrived to conduct the 1- year annual required inspection, there were two day care children in care. During the course of the inspection, it was discovered and confirmed that licensee’s adult son Dillon Johnson has been living in the home and did not have fingerprint clearance on file. At that time, LPA informed licensee that a citation will be issued and an immediate civil penalty of $500 will be assessed. Shortly after, licensee asked LPA to end the visit and to come back another day. LPA explained to licensee, that LPA must complete the visit today. Licensee insisted that LPA end the visit. At that point, LPA contacted LPM Chico, and LPM Chico spoke with licensee, reiterating that, in order for LPA to do her job LPA has to complete the inspection. Licensee again insisted that LPA end the visit because she cannot deal with this right now. LPM informed licensee that, since LPA is not allowed to complete the inspection, Licensee will also be cited for Inspection Authority. Visit ended and LPA left the facility at around 9:40am.

Based on the above mentioned, deficiencies cited on attached 809D
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 198003989
VISIT DATE: 02/07/2023
NARRATIVE
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Upon receipt of this report documenting a substantiated complaint allegation and a Type A deficiency, the licensee shall do the following:

1. Post the Notice of Site visit and any licensing report documenting a Type “A” deficiency.
2. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.
3. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year).
4. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this visit.

Exit interview was conducted with Pamela Johnson, licensee, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role. .
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 02/07/2023 11:56 AM - 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: JOHNSON FAMILY CHILD CARE
FACILITY NUMBER: 198003989

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.

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Licensee's son now has fingerprint clearance on file.

Correction has been corrected.
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The requirment is not met as evidenced by: On 1/31/2023, it was discovered/confirmed that licensee's adult son DIllon Johnson has been living at the facility did not have fingerprint clearance. This poses an immediate health and safety risk to children in care. Immediate civil penalty assessed.
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Type A
02/07/2023
Section Cited

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Inspection Authority of the Department. On 1/31/23, Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice to secure compliance .....
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Per licensee, will allow the department to conduct visit as required. Written statement will be submit by 2/10/23 due dated.
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On 1/31/23, LPA attempted to conduct an annual visit, LPA was asked to end the visit and toleave. The requirement is not met as evidenced by: Licensee did not allow LPA to complete visit on 1/31/23. This poses an immediate health & safety risk to children in care.
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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: Ana ChicoTELEPHONE: (323) 981-3374
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3