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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800640
Report Date: 07/28/2021
Date Signed: 07/28/2021 01:57:12 PM

Document Has Been Signed on 07/28/2021 01:57 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JOHNSON & JOHNSON RESIDENTIAL HOMEFACILITY NUMBER:
496800640
ADMINISTRATOR:FAYRETTA JOHNSONFACILITY TYPE:
740
ADDRESS:1259 SANTA INES WAYTELEPHONE:
(707) 763-6017
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 4DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator Fayretta JohnsonTIME COMPLETED:
01:58 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Administrator/Licensee Fayretta Johnson. LPA was met at the front door by licensee and had temperature taken and logged. All staff had masks on during this visit. Facility has 4 residents that all participate in home day program activities via one on one zooms. Facility has puzzles, outings, books, and other activity plans for residents during the day. Day programs have not reopened for in person learning as of yet.

During LPA facility tour on 7/28/2021 with administrator Johnson; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 01/01/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector was found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food was also stored in the garage refrigerator, finding to be properly stored as per regulations. Toxins are stored in a locked cabinet inside the garage. Dangerous items (toxins & knives/sizers) were locked under kitchen sink inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured from 108.5 degrees F to 109.5 degrees F., within acceptable regulations of 105 to 120 degrees F.

Infection Control:

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the office and garage. Facility has not hired or admitted anyone new since COVID-19. Residents’ medications are stored in locked cabinet in the kitchen. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit.

Continued on LIC809-C


SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: JOHNSON & JOHNSON RESIDENTIAL HOME
FACILITY NUMBER: 496800640
VISIT DATE: 07/28/2021
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LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms of COVID-19 + occurs in the facility.

In addition, facility has a designated area in the backyard for visitors which are being allowed for visits. Residents also have available Zoom, Facetime, and telephone calls when contacting family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing. Disaster drills are conducted on a quarterly basis with the last being performed 7/25/2021.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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