565850282-8-17-2022-29-AS-AASO-CHDQNN-20220817121926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850282
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:20:33 PM

Document Has Been Signed on 08/17/2022 12:20 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JOHNSON'S GUEST HOME		FACILITY NUMBER:	565850282
ADMINISTRATOR:	WILSON, RHETTA		FACILITY TYPE:	735
ADDRESS:	1252 TERESA ST		TELEPHONE:	(805) 351-5006
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY: 4		CENSUS: 0	DATE:	08/17/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Joseph Johnson		TIME COMPLETED:	11:10 AM

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) Angel Ascencio conducted a pre-licensing visit to the above facility. The LPA met with applicant, Joseph Johnson. This is a change in location. This is a level 2 Adult Residential Facility that is ventured through Tri-Counties Regional Center. The facility is two stories. At 9:15 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for four (4) ambulatory residents only. The facility has four (4) private resident bedrooms. All resident rooms have no direct exits to the outside. The facility has fire sprinklers. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # Six (6) is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms in the hallway. One (1) is designated as a staff bathroom. The resident bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are stored in afiling cabinet which is currently located in the Office Room # One (1). Medications are centrally stored in a locked closet by the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in the closet. Continued on LIC 809 - C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JOHNSON'S GUEST HOME	FACILITY NUMBER: 565850282
	VISIT DATE: 08/17/2022

NARRATIVE

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Kitchen knives are stored in the locked closet by the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in Laundry Room. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room, loft and dining area. There is sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All rugs contained nonslip material underneath. There is a fireplace in the living room. It is screened and there are no tools. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which can heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility fire sprinkler system is hard wired. There is a pull station at the front entry of the house. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There are two (2) of fire extinguishers throughout the house. They are fully charged and do not exceed the expiration date.

Hot water was tested in each bathroom, which included the resident bathroom(s) and any common bathrooms, in addition to the kitchen; and, the hot water was within normal ranges. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in a locked cabinet in the restrooms. Extra incontinence supplies are stored in the garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at in the hallways. The emergency telephone numbers and other required postings are posted in the hallways.

Continued on LIC 809- C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JOHNSON'S GUEST HOME	FACILITY NUMBER: 565850282
	VISIT DATE: 08/17/2022

NARRATIVE

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The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by gates. There is a gate with a self-latching mechanism for persons to enter the front and backyard. There is a locked storage shed in the back yard. There no any bodies of water on the premises at the present time. The garage is accessible from the house; the doors were locked.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022

LIC809 (FAS) - (06/04)

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