565850282-8-6-2025-29-AS-ECOZ-DKAQL8-20250806121532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850282
Report Date: 08/06/2025
Date Signed: 08/06/2025 12:28:36 PM

Document Has Been Signed on 08/06/2025 12:28 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 HOME		FACILITY NUMBER:	565850282
ADMINISTRATOR/ DIRECTOR:	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:	08/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Joe Johnsons/ Rhetta Wilson		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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	This report was amended to obtain Facility Representative signature on all pages. 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 10:28 a.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 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. 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 03/05/2025. 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. No bodies of water were observed. 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 WILL CONTINUE ON LIC809-C (2ND PAGE).

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 08/06/2025

NARRATIVE

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This report was amended to obtain Facility Representative's signature.

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 09:56 a.m. hot water temperature was 107.2*F in the 1st floor common restroom, and at 10:03 a.m. the hot water temperature was 106.4 F in the second floor common restroom.

MEDICATIONS: Medications review began at 10:30 a.m.; The LPA reviewed two (2) out of four (4) client's medications. Medications are centrally stored in a locked closet in the downstairs hall; medications are labeled and checked for expiration dates. 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).

RECORDS: At 11:00 a.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 08/01/2025).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 and current. The LPA reviewed one (1) staff file and observed there was no staff training on file.

INTERVIEWS: Interviews with 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 and appeals rights were provided to the administrator and Licensee.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/06/2025 12:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/06/2025 12:26 PM

Created By: Esther Cortez On 08/06/2025 at 12:03 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JOHNSON'S GUEST HOME	FACILITY NUMBER: 565850282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80065(f)

Personnel Requirements

(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one of three staff that did not have any training on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit proof off all required training for the staff by 08/20/25. This report was amended to obtain Facility Representative's signature.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC809 (FAS) - (06/04)

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