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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803381
Report Date: 05/24/2024
Date Signed: 05/24/2024 12:41:10 PM

Document Has Been Signed on 05/24/2024 12:41 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/
DIRECTOR:
TOLIVER, GRACEFACILITY TYPE:
735
ADDRESS:241 RONEY AVENUETELEPHONE:
(707) 642-5400
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 3DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:12 AM
MET WITH:Judy Johnson, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Jill Nakagawa conducted an unannounced Required 1 year inspection to Johnson Family Home, LLC and was welcomed by Co-Administrator, Judy Johnson. Administrator, Grace Toliver was available by phone at the time of the visit. The facility provides care for three clients. Licensee, Grace Toliver's Administrator Certification 6006091735 is valid through 8/15/2024.

LPA toured the facility with Judy Johnson, and found to be clean and at a comfortable temperature with all exits free from obstruction. Clients' bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on April 4, 2024. The Fire Department had made a recent inspection. Smoke detectors and carbon monoxide detector found to be functioning properly at the time of the visit. Hot water temperature measured 111 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 was supplied with individual paper towels; hand soap dispenser was also available. Client's 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.

Medication is found to be secured in locked closet located in the hallway. Clients are in charge of their own money and bank accounts are not commingled.

LPA requested the following documents be sent to CCL by COB 6/15/2024:


LIC 500 Personnel Summary, LIC 9020 Register of Facility Clients
No deficiencies cited during today's visit.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2024
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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