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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202538
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:05:03 AM


Document Has Been Signed on 03/19/2024 11:05 AM - 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:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Terry JohnsonTIME COMPLETED:
11:50 AM
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Today, Licensing Program Analyst L. Xiong arrived at the facility unannounced to conduct the Infection Control Inspection. LPAs met with Licensee/Administrator Terry Johnson and inform her the purpose of the visit.

LPA toured the facility with staff. Facility appeared clean with no obstruction or fire clearance issues. All common areas have adequate seating and lighting. Resident bedrooms toured, rooms observed to have all required accommodations. Kitchen toured, LPA observed a 2-day supply of perishable and a 7-day supply of non-perishable food available for residents.

Smoke detector and carbon monoxide detectors observed operational during inspection. Fire extinguisher present with a service date of 02/2024. Water temperature observed to measure at 120 degrees F.

No deficiencies were observed.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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