019200090-2-25-2025-15-AS-KHOS-DJZLQN-20250728085746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200090
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:48:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/04/2024 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20240304113429

FACILITY NAME:	JOHNSON'S FAMILY HOME, INC.		FACILITY NUMBER:	019200090
ADMINISTRATOR:	NATALIE JAYNE JOHNSON		FACILITY TYPE:	735
ADDRESS:	670 55TH STREET		TELEPHONE:	(510) 594-2274
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94609
CAPACITY:	6	CENSUS: 5	DATE:	02/25/2025
		UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	PAMELA TEMPLE, ASSISTANT ADMINISTRATOR		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not prevent resident from engaging in inappropriate behaviors
Staff are yelling at residents

INVESTIGATION FINDINGS:

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On 02/25/2025 at 12:16PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Pamela Temple, Assistant Administrator and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with Staff 1 (S1) Witness 1 (W1), client 2 (C2) and client 3 (C3). LPA reviewed and obtained client 1 (C1). current IPP, face sheet and February behavior tracking sheet, appraisal needs and service plan, medication management, behavior conditions, police report, and doctor’s statement.

CONTINUE ON LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240304113429

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOHNSON'S FAMILY HOME, INC.	FACILITY NUMBER: 019200090
	VISIT DATE: 02/25/2025

NARRATIVE

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CONTINUE FROM LIC 9099

Allegation: Staff did not prevent resident from engaging in inappropriate behaviors
Investigation Finding: unsubstantiated.

W1 reported that W1 witnessed C1 one night screaming and banging so hard the house was shaking, then it got quiet and started again W1 stated C1 behaviors should be addressed. W1 also stated a week prior to the 3^rd or 4^th of March at about 11pm W1 witnessed a light and C1 was naked and trying to get out of the room and was banging and was trying to take down the curtains and blinds all night long. W1 stated someone called the police because the client attacked a staff. W1 stated that if staff paid attention to the client C1 would not have screamed all night.

Interview with C2 revealed that revealed that C1 would hit and bite C2 and take C2 things from C2’s room.

Interview with C3 revealed that C1 attacked staff and the police was called and C1 punched C3 in the stomach. Interview with Administrator revealed that C1 has been having behaviors and C1 medication had been changed and is changed every few months.

Interview with Administrator revealed that C1 needs a higher level of care because medication management is no longer working C1 medication changed every 2 months and C1 is getting worse. Administrator C1 has been living in the facility 9 years, C1 has been knocking holes in the walls, and smears feces on the walls among other abusive behaviors towards the other clients such as hitting and biting. Administrator also stated that C1 was having behaviors at program and the police was called and C1 attacked a police officer, and it took 4 police officers to restrain C1.

CONTINUE ON LIC 9099C2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240304113429

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JOHNSON'S FAMILY HOME, INC.	FACILITY NUMBER: 019200090
	VISIT DATE: 02/25/2025

NARRATIVE

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CONTINUE FROM LIC9099C

Administrator stated that the clients are afraid of C1 when C1 has behaviors. Administrator also stated at this point C1 was admitted to the hospital. Therefore, this allegation is unsubstantiated.

Allegation: Staff are yelling at residents

Investigation Finding: unsubstantiated.

W1 reported hearing staff yelling at clients in the facility. W1 stated C1 was trying to get out of the room and W1 heard staff yelling at C1.

Interview with C2 revealed that staff has not yelled at C2 and never witnessed staff yelling at anyone.

Interview with C3 revealed that staff has not yelled at C3.

Interview with Administrator revealed that Staff dose not yell at the clients, staff and clients are mild mannered. Administrator stated yelling at the clients would be a violation of clients personal rights. Therefore, this allegation is unsubstantiated.

Interview with S2 revealed that S2 has not yelled at C1 and has never heard any other staff yelling at C1.

Interview with S3 revealed that S3 has not yelled at C1 and has never heard any staff yelling at C1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that Staff are not meeting client's personal care needs is unsubstantiated.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025

LIC9099 (FAS) - (06/04)

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