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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800640
Report Date: 07/12/2022
Date Signed: 07/12/2022 02:30:36 PM

Document Has Been Signed on 07/12/2022 02:30 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
07/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Fayretta JohnsonTIME COMPLETED:
02:30 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.

During LPA facility tour on 7/12/2022 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 01/14/2022 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/scissors ) were locked under kitchen sink inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. All bathrooms are supplied with paper towels and liquid hand soap. Hot water temperature measured from 110.3. degrees F to 111.5 degrees F.in 2 out of 2 residents bathrooms, within acceptable regulations of 105 to 120 degrees F. Resident’s are not attending day programs as of yet but do participate in on-line interactive virtual walks, national geographic activities and gardening. Facility offers activities of puzzles, bingo, painting, corn hole, outdoor porch swing, and some outings.

Infection Control:

Facility has submitted a mitigation program plan that has been approved and an Infection Control Plan. 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 centrally stored in locked cabinet in the kitchen. Facility has a 30-day supply of medications 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.
Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JOHNSON & JOHNSON RESIDENTIAL HOME
FACILITY NUMBER: 496800640
VISIT DATE: 07/12/2022
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In addition, facility has a designated area for visitors in the backyard, living room, and/or in the bedrooms when possible. Residents have also available Zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file and all have been N-95 fit tested.

LPA reviewed Licensing Information System (LIS) with licensee who stated that is corrected and updated at this time. In addition, LPA advised facility to contact County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed.
Administrator Certificate’s for Fayretta Johnson # 6018327740 Exp. 7/19/2022
All staff have received COVID booster vaccinations and exclusively work at this facility

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 7/29/2022 to SRRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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