565850282-8-2-2023-29-AS-TCAA-CUBV6V-20230802161011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850282
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:10:35 PM

Document Has Been Signed on 08/02/2023 04:10 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: 4	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:23 PM
MET WITH:	Rhetta Wilson		TIME COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with licensee Joseph Johnson and administrator Rhetta Wilson. This home is vendored by Tri-Counties Regional Center as a level two home.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. The facility has a supply of emergency food and water.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 05/26/2023. The carbon monoxide detector and smoke detectors were tested and operational. Cleaning supplies were observed to be locked in the laundry room and inaccessible to clients in care. The backyard has covered seating for client use.

BEDROOMS: There are four client bedrooms and one staff bedroom. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

(Report continued on LIC 809-C)

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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

FACILITY NAME: JOHNSON'S GUEST HOME	FACILITY NUMBER: 565850282
	VISIT DATE: 08/02/2023

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(continued from 809)

RESTROOMS: The facility has two common restrooms for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. Hot water temperature was 116.8*F.

MEDICATIONS: Medications are centrally stored in a locked closet in the downstairs hall. Medications for four clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: LPA reviewed P&I money and records with the licensee. Cash resources for all four clients were separate and intact, and not commingled with facility funds or petty cash. The four client files reviewed were found to be complete. Two staff files were reviewed and also found to be complete. Disaster drills are conducted monthly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file.

INTERVIEWS: Interviews with one staff and two clients were conducted. No issues or concerns revealed.

No deficiencies were cited during today's inspection. Exit interview and reported reviewed with the Administrator. A copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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