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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850282
Report Date: 08/27/2024
Date Signed: 08/27/2024 04:38:35 PM

Document Has Been Signed on 08/27/2024 04:38 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JOHNSON'S GUEST HOMEFACILITY NUMBER:
565850282
ADMINISTRATOR/
DIRECTOR:		WILSON, RHETTAFACILITY TYPE:
735
ADDRESS:1252 TERESA STTELEPHONE:
(805) 351-5006
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 4CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Joseph S. Johnson/Rhetta WilsonTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with licensee Joseph Johnson and explained the reason for the visit. This home is vendored by Tri-Counties Regional Center as a level two home. Administrator Rhetta Wilson arrived at the end of the vist at 03:42 p.m.

The LPA toured the physical plant areas inside and outside with the Licensee 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. Sharp items were observed to be locked in a closet and inaccessible to clients in care.
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 03/27/2024. 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. At 11:56 a.m. the LPA observed dust on the furniture in the common spaces.
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. At 11:33 a.m. and 11:52 a.m. the LPA observed the window screens with dust and spider webs in client bedrooms #2 and #5. At 11:51 a.m. the LPA observed a bottle of Tylenol Extra Strength caplets in client bedroom #4.
REPORT WILL CONTINUE ON LIC809-C (2ND PAGE).
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JOHNSON'S GUEST HOME
FACILITY NUMBER: 565850282
VISIT DATE: 08/27/2024
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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. At 11:42 a.m. hot water temperature was 114.8*F in the 1st floor common restroom, and at 11:55 a.m. the hot water temperature was 118.4 F in the second floor common restroom.

MEDICATIONS: Medications review began at 12:18 p.m.; medications are centrally stored in a locked closet in the downstairs hall; medications are labeled and checked for expiration dates. Medications for three 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 (CSMDR). The LPA inspected the first aid kit, which was complete.

RECORDS: At 1:50 p.m., a review of facility files was initiated. Facility records are stored in the locked office room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 08/02/2024).The LPA reviewed four (4) out of four (4) client files. 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. The facility has a 30 day supply of personal protective equipment.

INTERVIEWS: Interviews with two (2) staff and two (2) clients were conducted. No issues or concerns revealed.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Report was provided to the administrator and Licensee.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 04:38 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/27/2024 at 03:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JOHNSON'S GUEST HOME
FACILITY NUMBER: 565850282

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one of one Tylenol medication bottles observed in client's room who is not able to manage and store own medication which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Plan of correction has been met. Licensee removed bottle of Tylenol upon observation.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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