496800640-7-18-2023-21-AS-SHAN-CTUSH9-20230718135309

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800640
Report Date: 07/18/2023
Date Signed: 07/18/2023 01:53:17 PM

Document Has Been Signed on 07/18/2023 01:53 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 & JOHNSON RESIDENTIAL HOME		FACILITY NUMBER:	496800640
ADMINISTRATOR:	FAYRETTA JOHNSON		FACILITY TYPE:	740
ADDRESS:	1259 SANTA INES WAY		TELEPHONE:	(707) 763-6017
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 4	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Fayretta Johnson, Licensee/Administrator		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by Administrator/Licensee Fayretta Johnson. One resident had already left to attend their day program at the time of the visit. There are 4 clients in the facility. LPA toured the facility on 7/18/2023 at 9:20 AM with administrator/licensee Fayretta 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 2/2/2023 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 114.6 degrees F and 118.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 7/18/2023 at 9:30 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility garage. Garage also now contains a large screen TV with 6 reclying /vibrating chairs. Dangerous items were stored inaccessible to clients. 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 available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads. A review of four clients and a sample review of two staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 11:00 AM on 7/18/2023 and learned that 4 of 4 clients have an updated reappraisal/needs & care plan and physician’s report. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

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 & JOHNSON RESIDENTIAL HOME	FACILITY NUMBER: 496800640
	VISIT DATE: 07/18/2023

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P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingle, and ledgers are current on 7/18/2023. Medications were centrally stored in a locked closet cabinet in the kitchen of facility on 7/18/2023 although some medications were pre-poured for evening, LPA discussed Regulation 87465(h)(5) leaving medications in original containers until use not being transferred to any other containers (see LIC9102 Advisory Notes TV). LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 7/18/2023 at 1:00 PM. Centrally Stored Medication Records (CSMR) on 7/18/2023 at 1:10 PM .were missing a couple of medication pills for client C1. Licensee informed while providing C1 medication on a daily basis, some dropped on the floor needing to be destroyed although Licensee neglected to log in destruction log. C2 medication count was also not correct. (see confidential name list, LIC 812, LIC 9102 Advisory Notes)

LPA conducted a sample review of staff records on 7/18/2023 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of 1^st Aid certification for staff records that were reviewed. Fayetta Johnson Administrator Certificate # 6018327740 expires on 7/19/2024.
LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. Disaster Drills have been conducted often to allow all staff to participate with the last one being conducted on 4/19/2023

There were no deficiencies cited at this time.

LPA is requesting the following documents be submitted to CCL by 8/4/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Current Administrator's qualifications and Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC809 (FAS) - (06/04)

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