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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004557
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:51:33 AM

Document Has Been Signed on 11/02/2023 11:51 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
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
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:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Brennan Williams, Care staffTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to conduct an annual inspection. LPA met with Care staff Brennan Williams during today's inspection. LPA ensured they applied hand sanitizer before entering the facility.

LPA toured facility to ensure health and safety of clients in care. LPA toured 3 client rooms, 2 bathrooms, kitchen, common living spaces, backyard and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA toured the backyard and all exits are accessible and unlocked. There is a locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed an adequate amount of linens and found the first aid kit to be complete.

LPA reviewed 2 of 3 resident files and 2 staff files. LPA reviewed medications of two residents comparing with physician orders. A review of staff records indicates that all facility staff has received criminal record clearances and/or are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPA reviewed client P& I records and reviewed receipts.

LPA checked water temperature and observed water at 135 degrees. Deficiencies cited on 809-D. Appeal rights provided.

Exit interview conducted.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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Document Has Been Signed on 11/02/2023 11:51 AM - It Cannot Be Edited


Created By: Bethany Mirlohi On 11/02/2023 at 11:40 AM
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
, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: JOHNSON FAMILY HOME
FACILITY NUMBER: 317004557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above the water measuring to 135 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/06/2023
Plan of Correction
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Administrator agrees to lower water temperature and send LPA a picture of thermometer reflecting water temperature between 105 and 120 degrees. POC dues by 11/6/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Ordonez
LICENSING EVALUATOR NAME:Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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