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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200097
Report Date: 09/03/2024
Date Signed: 09/03/2024 03:01:22 PM

Document Has Been Signed on 09/03/2024 03:01 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/
DIRECTOR:
NATALIE JAYNE JOHNSONFACILITY TYPE:
735
ADDRESS:26854 PELHAM PLACETELEPHONE:
(510) 427-9579
CITY:HAYWARDSTATE: CAZIP CODE:
94542
CAPACITY: 6CENSUS: 5DATE:
09/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Natalie Jayne Johnson, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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On this day at around 12:15pm, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and was met by Administrator (Ad), Natalie Johnson LPA explained to AD the purpose of visit.

Facility is a two story 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 106 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 12/14/2023. 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. Sample 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 1 PM, LPA reviewed 5 client and 2 staff files. Last fire drill was conducted on 8/4/24. Facility has a pool that is fenced and locked.

There is no deficiency noted for today's visit.

Exit interview was conducted with Administrator and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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