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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004557
Report Date: 11/30/2022
Date Signed: 11/30/2022 03:47:02 PM

Document Has Been Signed on 11/30/2022 03:47 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
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:JOHNSON FAMILY HOMEFACILITY NUMBER:
317004557
ADMINISTRATOR:JOHNSON, GARY K.FACILITY TYPE:
735
ADDRESS:1940 AMBER FIELDS WAYTELEPHONE:
(916) 320-3772
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 3CENSUS: 3DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Xavier ManeewongTIME COMPLETED:
03:55 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
LPA Hiratsuka, conducted this unannounced annual visit. LPA wore a surgical mask and observed all staff wearing masks. LPA toured the facility with Caregiver Xavier Maneewong.

This facility has three private resident rooms. There is one full common bathroom and one full bathroom in a private room. The private room with the bathroom has an exit to the outside. There is no staff room. The garage is connected to the house through a door between the garage and common area. The kitchen was inspected. There is a dining nook in the kitchen. There is a gate on the same side as the garage. The common areas are well maintained.

-one of three resident files were reviewed
-staff files were reviewed
-a couple of topics were discussed with Caregiver.


The following shall be updated and submitted to licensing within 30 days;
LIC 500- facility personnel or staff schedule
LIC 308- designation of administrative responsibility
LIC 610- emergency disaster plan


No deficiencies cited.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2022
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 1