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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 092700121
Report Date: 09/27/2021
Date Signed: 09/28/2021 08:44:28 AM

Document Has Been Signed on 09/28/2021 08:44 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:JOHNSON'S FOOTHILL ADULT HOMEFACILITY NUMBER:
092700121
ADMINISTRATOR:PATRICIA & JASON JOHNSONFACILITY TYPE:
735
ADDRESS:3061 RANCHERIA DRIVETELEPHONE:
(530) 672-9281
CITY:SHINGLE SPRINGSSTATE: CAZIP CODE:
95682
CAPACITY: 4CENSUS: 1DATE:
09/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patricia JohnsonTIME COMPLETED:
10:15 AM
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Unannounced annual visit utilizing the infection control domain was performed by LPA Michael Smith. Contact with Patricia Johnson.

A review of staff records on 9/27/21 indicates that all facility staff and other individuals who require caregiver background checks have received criminal record clearances.

As a result of this visit, there were no deficiencies. However, 2 technical violations were issued.

Small family home with one (1) resident. Facility has requested N95 masks.

Exit interview conducted.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Michael Smith
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2021
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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