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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803381
Report Date: 06/22/2023
Date Signed: 06/22/2023 01:17:27 PM

Document Has Been Signed on 06/22/2023 01:17 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: 3DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Judy Johnson, Lead StaffTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – inspection for this facility and was greeted by Lead Staff, Clara Lindsay. House Manager, Judy Johnson and Administrator, Grace Toliver was also contacted and arrived later in the visit. The facility currently provides care for 3 clients all of which were present at the time of the inspection.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Lead Staff; facility was found to be clean and at a comfortable temperature. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 4/7/2023 at the time of the visit. Smoke and Carbon Monoxide detectors were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food containers labeled with appropriate dates. There was a supply of linens, hygiene products and paper products available for clients located in the hallway. All client’s bedrooms have lighting & appropriate furnishings with bedrooms well maintained and cleaned by staff. LPA conducted a file review for all clients and found documentation including medical assessments updated and in place. LPA found that 2 out of 3 clients have Needs & Service Plans in need to updating. Technical Violation issued, Administrator agrees to submit updated forms to CCLD. LPA conducted a review of all staff files and found staff to have updated 1st Aid & CPR certification and Direct Support Professionals training on file.

Facility conducts and records emergency disaster drills. LPA requested for Administrator to conduct drill on a quarterly basis moving forward. A storage located in the backyard was found to be secured. Backyard area is found to be cleared of any debris and emergency exits were unobstructed. During the inspection LPA observed a container of powder bleach located in client (C1) bedroom under an unsecured bathroom sink. Items was immediately removed and placed in secured designated office area. LPA was informed that the bedroom is occupied by a client (C1) that is temporarily residing in a rehabilitation center but has not resided in the home for 2 years due to recovery. Clients do not use the private bathroom located in C1's bedroom and is not an immediate risk to current clients in care. Technical Violation issued.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, LLC
FACILITY NUMBER: 486803381
VISIT DATE: 06/22/2023
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Medication is found to be secured in locked closed located in the hallway. A spot medication count was conducted for clients and found to be in order. The facility primarily utilized the Medication Administration Record (MAR) form indicating start and administering records of prescribed medications. The pharmacy partnered with the facility provides a printout of the prescribed medications, start dates and expiration dates; all information expected on Centrally Stored Medication Records. Clients are in charge of their own money and bank accounts and not commingled.


Licensee, Grace Toliver's Administrator Certification 6006091735 is valid through 8/15/2024.

LPA requested the following documents be sent to CCL by COB 7/22/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance


No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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