<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603300
Report Date: 02/03/2026
Date Signed: 02/03/2026 05:41:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/03/2026 05:41 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
MONTEREY PARK ASC, 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: 3DATE:
02/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:15 PM
MET WITH:Anthony Johnson, licenseeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
***This report supersedes the one issued on the same date 2/3/26 to add the plan of correction and obtain the licensee's signature.
Licensing Program Analyst (LPA) Cynthia Chan conducted the unannounced annual inspection on 2/3/26. LPA met with licensee, Anthony Johnson, and informed the reason for the visit. The facility is licensed for four (4) adults, ages 18 to 59, ambulatory only. There are currently (3) ambulatory clients residing at the facility, and were placed by the San Gabriel/Pomona Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the facility today.
The facility consists of (4) client bedrooms, 2 bathrooms, living room, dining room, kitchen, and a garage. There are no items obstructing the walkways. No swimming pool on the premises. The hot water temperature was measured at 134.7 degrees F in the bathroom. Knives and cleaning products are locked. Food supplies are sufficient. There is a carbon monoxide detector in the hallway and the operable smoke detectors are interconnected. The fire place is covered and not in use. Client rights and licensing poster are observed.
LPA reviewed (3) client files. The files have the required documents such as a medical assessment with TB test results and current IPP. P&I ledgers are signed when clients get their money. LPA reviewed the medications and they are being administered as prescribed. LPA reviewed (3) staff files. The administrator's certificate expires on 5/1/26. Staff have current CPR & First Aid certificates. The infection Control Plan and Emergency Disaster Plan were reviewed. LPA issued a technical violation to ensure that the Emergency Disaster Plan is being reviewed annually. Emergency Disaster drills are being conducted at least quarterly.
A deficiency is issued today for the water temperature. Technical violations are also given.
An exit interview was held. A copy of this report and appeal rights were given to the administrator.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 02/03/2026 05:41 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 02/03/2026 at 03:18 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JOHNSON FAMILY HOME
FACILITY NUMBER: 198603300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/04/2026
Section Cited
CCR
80088(e)(1)

1
2
3
4
5
6
7
80088 Fixtures, Furniture, Equipment, and Supplies (1) Hot water temperature controls shall be maintained...not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall submit a plan to ensure the hot water temperature is within the require range of 105-120 degrees F. The plan shall be submitted to LPA by 2/4/26.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above in which the bathroom is measured at 134.7 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Fernando Fierros
NAME OF LICENSING PROGRAM MANAGER:
Cynthia D Chan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3