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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700605
Report Date: 08/29/2023
Date Signed: 08/30/2023 07:49:35 AM

Document Has Been Signed on 08/30/2023 07:49 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
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: 4DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Juliet RamonesTIME COMPLETED:
03:00 PM
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On 08/29/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with staff member, Marilyn Garcia. LPA asked that SM Garcia call the Facility Designated Administrator at this time to inform them that CCL was present. LPA Pascua was informed that the Facility Designated Administrator was unable to come at this time but will join the visit later in the day. LPA Pascua was able to continue the visit with SM Garcia at this time.
This facility is licensed to serve and retain 6 non-ambulatory residents, 1 of which may be bedridden. This facility also has a dementia plan on file and has a hospice waiver for 6.
Current census was 4.
LPA Pascua reviewed 4 resident files. It was learned that 2 of 4 residents were receiving hospice services. 4 out 4 resident files were current and up to date. LPA reviewed 4 staff files. 4 out of 4 staff files were current and up to date. The administrator has a current administrator certificate #6047790740 and expires on 04/02/2024.
A tour of the facility was conducted.
Fire extinguisher appeared to have been annually inspected by Armor Fire on 07/14/2023.
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: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: JOHANAN CARE HOME INC
FACILITY NUMBER: 392700605
VISIT DATE: 08/29/2023
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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

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to Licensee, Juliet Ramones.

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

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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