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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603300
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:28:20 PM

Document Has Been Signed on 01/09/2025 03:28 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JOHNSON FAMILY HOMEFACILITY NUMBER:
198603300
ADMINISTRATOR/
DIRECTOR:		JOHNSON, ANTHONYFACILITY TYPE:
735
ADDRESS:15355 LAS VECINAS DRIVETELEPHONE:
(323) 804-5062
CITY:LA PUENTESTATE: CAZIP CODE:
91744
CAPACITY: 4CENSUS: 4DATE:
01/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Anthony Johnson TIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Anthony Johnson and the purpose of the visit was discussed. The following (CARE) tool domains were utilized during the inspection:

Infection Control:
  • Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. The facility has an Infection Control Plan for LPA to review.
Operational Requirements:
  • A current Plan of Operation was reviewed.
  • A fire clearance for Four (4) clients of which (0) may be non ambulatory;0 may be bedridden.
Physical Plant/Environment Safety:
  • The facility is a single-story home located in a residential area. A tour of the facility includes: living room, dining area, kitchen, 4 bedrooms, 2 bathrooms (one is a private full bath within the client bedroom), attached garage with laundry and storage, front yard and back yard.
  • The physical plant was inspected. Facility is clean and in good repair. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to clients. Fire Alarms were inspected. Fire extinguishers Observed
  • Water temperature readings measured within the required 105 - 120 degrees Fahrenheit.
Staffing
  • Sufficient staff observed to meet clients needs
  • Facility currently provides care and supervision for a total of Four (4) Clients.
Client Rights-Information
  • No postural Supports Observed
  • Internet source provided to clients in care
Continued on LIC 809-C
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JOHNSON FAMILY HOME
FACILITY NUMBER: 198603300
VISIT DATE: 01/09/2025
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Personnel Records-Training:
  • Administrator on record current and Administrator Certification is active
  • Staff have criminal background clearance and training.
  • Four (4) staff files were reviewed. Proof of staff training, health clearance, and 1st Aid/CPR training was observed. Staff file have criminal record clearances and are associated.
Client Records-Incident Reports:
  • A total of Four (4) client files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment / IPPs, Physician's Orders, medical consent, and medication records.
  • Complaint poster and Personal rights were observed posted.
Health Related Services:
  • Four (4) Client centrally stored medications were reviewed.
Food Service:
  • Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies observed.
  • Sanitation practices and kitchen cleanliness was observed.
Incident Medical and Dental:
  • There are no clients in care with restricted or prohibited health conditions.
  • Individual Service Plans and Appraisals are on file.
Disaster Preparedness:
  • Emergency and Disaster Plan LIC 610 is in place.
Emergency Intervention:
  • None used at this time


All (12) domains have been completed as of todays visit. Per California Code of Regulations, Title 22, no deficiencies are being cited. Exit Interview was conducted. A copy of this report was provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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