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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 317004557
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:02:39 PM

Document Has Been Signed on 10/24/2024 02:02 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JOHNSON FAMILY HOMEFACILITY NUMBER:
317004557
ADMINISTRATOR/
DIRECTOR:
JOHNSON, GARY K.FACILITY TYPE:
735
ADDRESS:1940 AMBER FIELDS WAYTELEPHONE:
(916) 320-3772
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY: 3CENSUS: 3DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Brennan WilliamsTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Kerry Hiratsuka arrived unannounced to conduct an annual inspection. LPAs met with Care Staff Brennan Williams during today's inspection.

LPAs toured facility to ensure health and safety of clients in care. LPAs toured 3 client rooms, 1 bathroom, kitchen, common living spaces, and the garage area. In the areas toured no immediate health, safety, or personal rights violations were observed. There is locked storage for medications and toxins. Food supply is adequate for 2-day perishable and 7-day nonperishable.

LPAs reviewed three (3) resident files and three (3) staff files. LPAs reviewed medications of one resident comparing with physician orders. A review of staff records indicates that all facility staff have received criminal record clearances and are associated to this facility. Staff records reviewed indicated current first aid certificates and training completed. LPAs reviewed emergency drill log which is being conducted by the facility monthly.

LPAs reminded facility that annual fee of $454.00 due date is coming up.

No deficiencies are being cited as a result of todays inspection.

Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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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