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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700605
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:46:24 PM

Document Has Been Signed on 07/22/2021 04:46 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JOHANAN CARE HOME INCFACILITY NUMBER:
392700605
ADMINISTRATOR:RAMONES, JULIET BFACILITY TYPE:
740
ADDRESS:13754 JASPER STREETTELEPHONE:
(209) 679-6411
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 2DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Juliett Ramones, Administrator (AD).TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Arlene Garcia conducted an unannounced annual / Infection Control visit on this date. LPA was greeted by Marilyn Garcia, Caregiver (S1). LPA met with Mario Ramones (S2), and Juliett Ramones, Administrator (AD).

LPA and AD, inspected physical plant including but not limited to the main kitchen, residents bedrooms and bathrooms, and dining/ living room areas.

LPA observed sufficient 7 days nonperishable/2 days perishable food supplies.. Hot water temperature measured 113.7 degrees in residents bathroom. LPA observed sharps locked.
Last Fire Drill conduced dated 3/10/21. Fire extinguisher maintained 6/14//2021.
Fire alarm and carbon monoxide functional.

LPA observed all the required poster/documents posted. LPA reviewed 3 staff and 2 resident files. Resident emergency contact complete. LPA observed all staff files complete. Administrator Certificate valid until 4/2/2022.
All persons in facility fully vaccinated. LPA observed resident practicing social distancing. LPA observed 30 days PPE supply.

809 CONT. >>>>>>>>>>>>>>>
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: JOHANAN CARE HOME INC
FACILITY NUMBER: 392700605
VISIT DATE: 07/22/2021
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809 CONT. >>>>>>>>>>>>>>>>>

LPA and AD observed centrally stored medications hallway cabinets. LPA observed bottom cabinet where emergency evacuation supplies are kept had medications stored and was unlocked. LPA observed toxins in Resident (R1) restroom stored in medicine cabinet and on counter that were not locked.

LPA observed both resident rooms and staff bedroom. LPA observed hospital beds in residents room with half rails. R1 is on hospice. LPA reviewed records and found no hospital orders for R2 use of hospital bed with postural support.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited today in violation of California Code of Regulations. Exit interview held with AD and a copy of report given via email.


SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2021 04:46 PM - It Cannot Be Edited


Created By: Arlene D Garcia On 07/22/2021 at 02:24 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JOHANAN CARE HOME INC
FACILITY NUMBER: 392700605

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2021
Section Cited

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87705(f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:

(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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This requirement was not met with evidence by: LPA observed bottom cabinet where emergency evacuation supplies are kept had medications stored and was unlocked. LPA observed toxins in Resident (R1) restroom stored in medicine cabinet and on counter that were not locked. This is an immediate threat to health and safety of resident.
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Type B
07/22/2021
Section Cited

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87608(a)(3) Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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This regulation was not met by evidnece by: Records reviewed show no doctor orders for resident (R2) that had a hospital bed with half rails.This is an potential threat to health and safety of resident.
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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:Stephenie Doub
LICENSING EVALUATOR NAME:Arlene D Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


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