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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005900
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:46:49 AM

Document Has Been Signed on 12/05/2024 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JOHNSON SENIOR CAREFACILITY NUMBER:
306005900
ADMINISTRATOR/
DIRECTOR:		RAMIREZ, BREANNAFACILITY TYPE:
740
ADDRESS:3088 JOHNSON AVE.TELEPHONE:
(714) 957-1128
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:08 AM
MET WITH:Denice Figueroa-Caregiver, Breanna Ramirez-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:02 PM
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Nancy Guillen conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Denise Figueroa. Administrator (AD) Breanna Ramirez arrived shortly after.

For today’s visit, LPAs observed a total of six residents in care and two staff members on duty.

During today's visit LPAs observed the AD certificate for AD Breanna Ramirez which expires on February 12, 2025.

LPAs toured the interior and exterior portions of the facility with AD Ramirez. The facility is a one story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of five bedrooms, of which five are resident bedrooms. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 110.8 and 111.0 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located by the kitchen. Fire extinguisher was last service on July 30, 2024.

LPAs observed the emergency disaster and evacuation plan which is located by living room. Facility had back-up emergency food and water supply.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JOHNSON SENIOR CARE
FACILITY NUMBER: 306005900
VISIT DATE: 12/05/2024
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LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPAs reviewed four resident files and two staff files. LPAs interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised AD Ramirez to use the general email address:


CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Ramirez.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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