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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200090
Report Date: 06/21/2022
Date Signed: 06/21/2022 12:20:25 PM

Document Has Been Signed on 06/21/2022 12:20 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JOHNSON'S FAMILY HOME, INC.FACILITY NUMBER:
019200090
ADMINISTRATOR:NATALIE JAYNE JOHNSONFACILITY TYPE:
735
ADDRESS:670 55TH STREETTELEPHONE:
(510) 549-2274
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 6CENSUS: 5DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Staff, Pamela TempleTIME COMPLETED:
12:30 PM
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On 6/21/22 at 10:20am, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct infection control inspection. No client and staff were at facility. LPA called Administrator Natalie Johnson, she stated that she is currently out of town, clients might be at school, and staff left facility. She called staff Pamela Temple who arrived at 10:53am. LPA met with staff and explained the purpose of the visit.

LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, common areas, and outdoor areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy and hand sanitizer were observed at screening station. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has adequate supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted with staff, and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2022
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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