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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803381
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:24:36 PM

Document Has Been Signed on 06/14/2022 02:24 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JOHNSON FAMILY HOME, LLCFACILITY NUMBER:
486803381
ADMINISTRATOR:TOLIVER, GRACEFACILITY TYPE:
735
ADDRESS:241 RONEY AVENUETELEPHONE:
(707) 642-5400
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Judy Johnson, Lead StaffTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Required 1 year inspection to Johnson Family Home, LLC and was welcome by Lead Staff, Judy Johnson. Administrator, Grace Toliver was contacted and notified but unavailable at the time of the visit. The facility provides care for four clients, two of which were present, one of which was at work, and one of which currently admitted in rehabilitation center at the time of visit.

LPA continued the visit and toured the facility with Lead Staff Judy Johnson, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on May 6, 2022 at the time of the visit. Facility smoke detectors and carbon monoxide were tested found to be functioning properly at the time of the visit. Hot water temperature measured 107.4 degrees F which is within regulation between 105 and 120 degrees F. There was a ample supply of both perishable and nonperishable foods as required by Title 22 Regulations with proper labeling and storage. There was a supply of cleaners, hygiene products and paper products available for clients.

The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was also available. Clients bedrooms were found to be clean and have all appropriate furnishing. LPA reviewed staff files and confirmed that all staff have updated 1st Aid & CPR training on file.


Infection Control:
Facility has submitted a mitigation program plan and has been approved at the time of visit. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and clients are screened for temperature and symptoms on a daily basis and recorded.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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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