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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200090
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:02:15 PM

Document Has Been Signed on 06/20/2024 12:02 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JOHNSON'S FAMILY HOME, INC.FACILITY NUMBER:
019200090
ADMINISTRATOR/
DIRECTOR:		NATALIE JAYNE JOHNSONFACILITY TYPE:
735
ADDRESS:670 55TH STREETTELEPHONE:
(510) 594-2274
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 6CENSUS: 5DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Martine Yowea, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 6/20/2024 starting at 10:00 AM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Martine Yowea, Caregiver and explained the purpose of visit. Martine, caregiver contacted Natalie Jayne Johns, Administrator advised purpose of visit. Administrator arrived at 10:30AM. Administrators certificate (#6001411735) is valid and expires on 05/29/2025. The facility’s fire clearance was approved for all six (6) ambulatory clients.

LPA toured facility with Caregiver and ADM including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which three bedrooms are shared, and one (1) staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in clients’ common area bathroom was measured at 110.2 Degrees Fahrenheit. Clients’ bathrooms are equipped non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Sharps and toxins were locked and inaccessible to clients'.

Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 12/07/2023. Fire Drill last conducted on 03/10/2024. First aid kit was observed to be complete.



Continue on LIC809-C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JOHNSON'S FAMILY HOME, INC.
FACILITY NUMBER: 019200090
VISIT DATE: 06/20/2024
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Continued from LIC809.

LPA reviewed three (3) client records and three (3) staff records, and they were current and complete. LPA also reviewed P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 06/27/2024:

· Liability insurance.
· Surety Bond
· LIC500 (Personnel Record)
· Client Roster
· LIC308 (Designation of facility Responsibility)
· LIC400 Affidavit Regarding Client/Resident Cash Resources
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No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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