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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005900
Report Date: 11/04/2022
Date Signed: 11/04/2022 01:49:54 PM


Document Has Been Signed on 11/04/2022 01:49 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:JOHNSON SENIOR CAREFACILITY NUMBER:
306005900
ADMINISTRATOR:RAMIREZ, BREANNAFACILITY TYPE:
740
ADDRESS:3088 JOHNSON AVE.TELEPHONE:
(714) 957-1128
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Debedelia VelaTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Johnson Senior Care to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 1:00pm, LPA Cho was greeted and granted entry by Caregiver Debedelia Vela. Also present was Caregiver Adalila Gordillo Rodriguez. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station that required COVID-19 screening for all visitors which had temperatures documented on a sign-in sheet. LPA observed the required COVID-19 precautionary signs posted on the front entrance and throughout the facility. The Complaint Poster (PUB475) met the Department size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which two are receiving hospice care. The Administrator's Certificate for Breanna Ramirez expires on 02/12/2023. At 1:05pm, LPA Cho contacted Administrator (Admin) Breanna Ramirez and received verbal consent in the presence of Caregiver Debedelia Vela and consented Caregiver Vela to assist LPA with the tour and to sign the report.

At 1:13pm, LPA Cho conducted a tour of the physical plant with Caregiver Debedelia Vela. There are a total of five resident bedrooms and two resident bathrooms. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked with hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 112.8 degrees Fahrenheit in resident Bathroom #1 and 116.2 degrees Fahrenheit in resident Bathroom #2. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 06/28/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JOHNSON SENIOR CARE
FACILITY NUMBER: 306005900
VISIT DATE: 11/04/2022
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 LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. The exit gate was self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Caregiver Debedelia Vela, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC809 (FAS) - (06/04)
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