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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202538
Report Date: 05/31/2022
Date Signed: 05/31/2022 01:07:58 PM


Document Has Been Signed on 05/31/2022 01:07 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:JOHNSON HOME 112 INC.FACILITY NUMBER:
547202538
ADMINISTRATOR:JOHNSON, TERRIFACILITY TYPE:
740
ADDRESS:22419 AVE 112TELEPHONE:
(559) 744-9118
CITY:PORTERVILLESTATE: CAZIP CODE:
93257
CAPACITY:6CENSUS: 4DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Terri JohnsonTIME COMPLETED:
12:51 PM
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On 5/31/2022, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self and allowed entrance by Direct Support Person (DSP I) Anna Arechiga. Licensee/Administrator, Terri Johnson contacted by telephone and arrived a short time later to conduct inspection. A tour of the facility was conducted, COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point, all staff and visitors enter through side door.

Four (4) residents present during today's inspection, all observed to be participating in day program activities at time of arrival. Facility appeared clean, well lit and with no obstruction or fire clearance issues. Adequate seating available in all common areas of facility, social distancing observed to be maintained. Hand washing posters were observed by the bathroom sink. Resident bedrooms toured, all resident bedrooms observed to have a minimum of 6 feet between beds. LPA observed 2-day supply of perishable and 7-day supply of non-perishable food available. All medications observed to be locked and secured in medication closet in laundry area. PPE supplies observed to be available.

Fire extinguisher present and has a service date of 01/27/2022. Carbon monoxide detector and smoke detectors present and observed to be operational during today's inspection.

LPA received copies of Administrator Certificate, First Aid and LIC 500 during facility inspection.

No deficiencies observed during inspection.

Exit interview conducted. Facility report signed at time of inspection. Copy of report provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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