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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005900
Report Date: 12/01/2021
Date Signed: 12/03/2021 05:29:17 PM

Document Has Been Signed on 12/03/2021 05:29 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JOHNSON SENIOR CAREFACILITY NUMBER:
306005900
ADMINISTRATOR:RAMIREZ, BREANNAFACILITY TYPE:
740
ADDRESS:3088 JOHNSON AVE.TELEPHONE:
(714) 957-1128
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
12/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Caregiver Erlinda Ibarra. TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Erlinda Ibarra.

LPA Frank toured the facility. There are five clients residing in the facility and no active COVID-19 cases. All resident and staff are vaccinated. LPA observed five clients on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Residents bedrooms appeared clean and sanitary and had all required components. LPA Frank tested the hot water temperature, which measured 119.2 degrees F in resident bathroom. Resident areas were noted to be a comfortable temperature. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. The facility is still conducting COVID-19 testing as required by the latest guidance.

No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Shobhana Frank
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2021
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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