<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700605
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:45:16 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/27/2022 02:45 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: 3DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mario and Juliet Ramones TIME COMPLETED:
11:15 AM
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
Licensing Program Analyst (LPA) Arielle Pascua and Licensing Program Manager (LPM) Stephenie Doub arrived at this facility on 07/27/2022 at 9:00am to conduct an unannounced annual visit. LPA Pascua and LPM Doub were greeted by Marilyn Ramones and was told to contact the Administrator at this time to let them know that Licensing was present. LPA Pascua and LPM Doub later met with Facility Designated Administrators, Mario and Juliet Ramones and stated the purpose for today’s visit.
Census was currently 3. Two residents were on hospice at this time. Administrator holds current certificate and expires on 04/02/2024. The facility is licensed for six non-ambulatory. This facility also holds a hospice waiver for 6 residents. A tour of this facility was conducted. The facility has a main entrance screening point. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.
Fire extinguisher appeared to have been annually inspected on 07/28/2022.
The kitchen area was toured. LPA observed a sufficient seven days of non-perishable as well as two days worth of perishable food supplies in the main kitchen.
The exterior of the physical plant was toured. The two exit gates were inspected and perimeter fence was observed to be stable.
The common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.
Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time.
A tour of 3 resident rooms were conducted. Resident furniture was observed to be sufficient to meet resident needs at this time. A staff room was also toured.
A linen closet was located in the hallway and presented a sufficient amount of linen to adequately supply and meet the needs of the residents at this time.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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 3
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: 07/27/2022
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
26
27
28
29
30
31
32
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. Grab bars were present at this time.

LPAs observed a locked centralized stored medication cabinet located in the hallway. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components at this time.

The following forms and documents were requested to be updated and submitted into CCL:

-LIC 308

-LIC 400

-LIC 500

-LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code.

Appeal rights were printed and a copy of this report was given to the Facility Designated Administrator.

Exit Interview.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/27/2022 02:45 PM - It Cannot Be Edited


Created By: Arielle Pascua On 07/27/2022 at 11:02 AM
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: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2022
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintanence and Operations
(a) The facility shall be clean, safe, and sanitary and in good repair at all times.
This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by the LPA observed the kitchen cabinet latches
1
2
3
4
5
6
7
Licensee agrees to fix the kitchen latches and locks and provide a picture to the LPA's email by 08/03/2022.
8
9
10
11
12
13
14
and locks to be broken, which poses a potential health, safety or personal rights risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3