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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700605
Report Date: 08/22/2024
Date Signed: 08/27/2024 03:00:37 PM

Document Has Been Signed on 08/27/2024 03:00 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JOHANAN CARE HOME INCFACILITY NUMBER:
392700605
ADMINISTRATOR/
DIRECTOR:
RAMONES, JULIET BFACILITY TYPE:
740
ADDRESS:13754 JASPER STREETTELEPHONE:
(209) 679-6411
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Marilyn GarciaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Unannounced Plan of Correction visit made out to this facility on 08/22/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Marilyn Garcia. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Juliet Ramones, to inform her that CCL was present at this time.
Current census was 4 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 08/12/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 08/12/2024:
  • Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.


This facility did complete the Plan of Correction and provided all of the required forms and documents at this time.
Plan of Correction clearance letters were printed and copies were provided to the facility staff person at this time.

There were no further deficiencies observed or cited during today's Plan of Correction visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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