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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200097
Report Date: 04/11/2023
Date Signed: 04/11/2023 03:04:46 PM

Document Has Been Signed on 04/11/2023 03:04 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 INCFACILITY NUMBER:
019200097
ADMINISTRATOR:NATALIE JAYNE JOHNSONFACILITY TYPE:
735
ADDRESS:26854 PELHAM PLACETELEPHONE:
(510) 427-9579
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 6DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Natalie JohnsonTIME COMPLETED:
03:15 PM
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On this day at around 10:10 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and was met by staff Geneva Renfro. LPA explained to Geneva the purpose of visit. Administrator Natalie Johnson arrived at around 1:10 pm.

Facility is a two storey structure with 1 shared client room on the lower level and 3 other rooms on the second level, one of which is the staff room and the 2 shared client rooms. One staff room is located next to the dining area. Facility was observed to be clean and odor free. There were sufficient lighting and furniture.
Hot water measured at 111 degrees Fahrenheit in the bathroom and kitchen. There was sufficient supply of perishable and non perishable foods. Chemicals were observed locked in the laundry room. Medications and sharp objects/knives were locked separately. Hallways and passageways were free of obstruction. Fire extinguisher appeared full and was last serviced on 1215/2022 . Facility has a dual carbon monoxide and smoke detector that were tested and observed operational. Bath/shower rooms were observed with grab bars, non skid mats and hygiene products. Ample supply of linen, towels and warm blankets were observed. First aid kit was complete.

No client was present during inspection. Administrator states all clients are at their respective day programs.

At around 11 am, LPA reviewed 2 client and 2 staff files. At around 12:15 pm, LPA reviewed Medication Administration Record (MAR) and medication for 2 clients. At 2:10 pm, LPA interviewed 2 staff. LPA attempted to interview 2 clients. Last fire drill was conducted on January 2023.

At around 10:25 am, LPA observed steak knife unlocked in one of the drawers in the kitchen. LPA asked staff to lock knife during inspection.
*****continuation on Lic 809C*****
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JOHNSON'S FAMILY HOME INC
FACILITY NUMBER: 019200097
VISIT DATE: 04/11/2023
NARRATIVE
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Type B deficiency is cited per California Code of Regulations, Title 22 and listed on Lic 809D.

Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/11/2023 03:04 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 04/11/2023 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOHNSON'S FAMILY HOME INC
FACILITY NUMBER: 019200097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in leaving steak knife unlocked in one of the kitchen drawers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2023
Plan of Correction
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Staff locked knife during inspection. Deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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