Johnson & Johnson Residential Home

Type of visit: Office

An office meeting was conducted today in the Santa Rosa Regional Office with Licensing Program Manager Bethany Moellers and Licensing Program Analyst Shannan Hansen, Designee of the facility, Teri Johnson and Roland Johnson, Dominic Hebert, and Destiny Williams, regarding possible Emergency Approval to Operate (EAO) process for Johnson & Johnson Residential Home # 496800640 as the licensee passed away. Teri Johnson and Roland Johnson will continue the operation of this facility. Currently, there are 4 clients in care. During today's meeting, both parties indicated their intention to continue to operate the facility and an Emergency Approval to Operate (EAO) was issued during today's meeting. Parties were informed to ensure communication with regional center regarding venderization. Facility representatives provided the following documents: - LIC200. - LIC500. - Control of property – Trust Documents. - Fire Clearance Sketch (LIC999) - Administrator Cert - Proof of Orientation for Registration - Document confirming passing Continue on LIC809-C Continued from LIC809 - Application fee - Lease Agreement Completion of Orientation provide Certificate, when available Death Certificate, LIC610E (Emergency Disaster Plan) & Infection Control Plan. Regional Office will provide all documents received to the centralized application unit and advised applicant to follow up with additional requirements to obtain licensure. Contact for CAB- Central Application Unit Bureau: Fax: (916) 651-7916 744 P Street, MS 9-14-8201, Sacramento, CA 95814 Phone: (833) 827-6084 Email: CCLASCPCAB@dss.ca.govthe state’s words, verbatim · CDSS document, Aug 31, 2026

Type of visit: Required - 1 Year

At approximately 8:30 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to conduct a Required 1 Year visit and was greeted by Back-Up Administrator (BUA) Teri Johnson. Administrator Fayretta Johnson was not at the facility during today's inspection. Johnson & Johnson Residential Home is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a single story ranch house. The facility has an approved fire clearance for six (6) residents, four (4) of whom may be non-ambulatory. The facility has a Hospice Waiver for two (2) residents. Upon arrival, LPA was informed that there were four (4) residents in care and two (2) staff members on-site. At approximately 8:50 AM, LPA reviewed the Facility's Staff Roster and observed that staff member S1 has not been cleared on the Guardian Background Check System. This deficiency will be cited and a $100 Civil Penalty will be issued. All other staff members were observed to be background cleared and associated to the facility per regulation. At approximately 9:05 AM, LPA toured the facility with BUA Johnson. All exits were clear and unobstructed. The facility's one (1) fire extinguisher was last serviced and tagged on 4/18/2026. The facility was sufficiently lighted. LPA inspected three (3) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. The facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Continued on 809-C... ...Continued from 809 Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. At approximately 10:10 AM, LPA reviewed four (4) resident files. Four (4) of four (4) resident files were observed with all required documentation. LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date. Fayretta Johnson’s Administrator Certification renewal was received by the department on 6/18/2026. Teri Johnson’s Administrator Certification 7002200740 is current with an expiration date of 8/24/2027. LPA requested the following documents be submitted to Community Care Licensing by 8/30/2026: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Proof of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D, LIC-421BG, Plan of Corrections, 811 Confidential Names and Appeal Rights discussed and provided to BUA Johnson. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 31, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

8/12/2025 Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by Administrator/Licensee Fayretta Johnson. Facility is a residential care home for the elderly, which is a care home for Regional Center clients. This single story building with 3 resident bedrooms has fire clearance for six (6)= four (4) Non-ambulatory & two (2) Ambulatory, with a Hospice waiver for two (2). One resident had left to attend their day program at the time of the visit. There are 4 clients in the facility. LPA toured the facility on 8/12/2025 at 12:10 PM with licensee/administrator Fayretta Johnson, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last inspected on 4/4/2025 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 109 degrees F and 110.4 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 8/12/2025. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. Bathrooms were equipped with necessary grab bars, and slip-resistant mats, strips, or flooring in all bathtub and shower floors as required by Title 22 regulations All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads. Continue on LIC809-C Continued from LIC809 A review of four clients and four staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 12:40 PM on 8/12/2025 and learned that 4 of 4 clients have an updated reappraisal/needs & care plan and physician’s report. LPA conducted a sample review of staff records on 8/12/2025 at 1:20PM and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training and current 1st Aid certification for staff records that were reviewed. P&I monies are kept in a locked file cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P&I and ledgers available during the visit. P& I money not comingled, and ledgers are current on 8/12/2025. Medications were centrally stored in a locked closet cabinet in the kitchen of facility on 8/12/2025. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 8/12/2025 at 2:05 PM. Centrally Stored Medication Records (CSMR) on 8/12/2025 were found to be current. Fayetta Johnson's Administrator Certificate # 7005425740 expired on 7/19/2026. LPA. Disaster Drills have been conducted often to allow all staff to participate with the last one being conducted on 4/11/2025. Facility has 2 gas generators in case of emergency power outage. There were no deficiencies cited at this time. LPA is requesting the following documents be submitted to CCL by 8/29/2025: LIC 400 Affidavit Regarding Resident Cash Resources LIC 402 Surety Bond (if applicable) LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s Copy of Current Liability Insurancethe state’s words, verbatim · CDSS document, Aug 12, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual Required 1 yr. inspection to this facility and was welcome by Administrator/Licensee Fayretta Johnson. One resident had already left to attend their day program at the time of the visit. There are 4 clients in the facility. LPA toured the facility on 7/22/2024 at 11:15 AM with administrator/licensee Fayretta Johnson, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/30/2024 at the time of the visit. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit. Hot water temperature measured between 105 degrees F and 108.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 client’s bathroom while touring facility on 7/22/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet inside the facility garage. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. The bathroom designated for clients at the facility were supplied with individual paper towels; hand soap dispenser was available. All client’s bedrooms have lighting & appropriate furnishings, and beds were outfitted with mattress pads. A review of four clients and a sample review of two staff records as well as two client’s medications was conducted. LPA reviewed client’s files at 12:15 PM on 7/22/2024 and learned that 4 of 4 clients have an updated reappraisal/needs & care plan and physician’s report. LPA conducted a sample review of staff records on 7/22/2024 at 1:00 and learned that all staff present at the facility and other individuals who require caregiver background checks have received criminal record clearances or exemptions. Facility has proof of Direct care staff training. LPA was presented with proof of 1st Aid certification for staff records that were reviewed. Continue LIC 809-C P&I's are kept in a locked filed cabinet in the facility office room; facility responsible for all client’s P&I and money; facility had P& I and ledgers available during the visit. P& I money not comingled, and ledgers are current on 7/22/2024. Medications were centrally stored in a locked closet cabinet in the kitchen of facility on 7/22/2024. LPA conducted a review of medications for two clients. The Medications of 2 of 2 clients were found to be given according to physicians’ directions on 7/22/2024 at 1:50 PM. Centrally Stored Medication Records (CSMR) on 7/22/2024 were found to be current. Fayetta Johnson's Administrator Certificate # 6018327740 expired on 7/19/2024, LPA observed proof of pending certificate. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time. Disaster Drills have been conducted often to allow all staff to participate with the last one being conducted on 7/6/2024. There were no deficiencies cited at this time. LPA is requesting the following documents be submitted to CCL by 8/5/2024: LIC 400 Affidavit Regarding Resident Cash Resources LIC 402 Surety Bond (if applicable) LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility Resident’s Copy of Current Liability Insurancethe state’s words, verbatim · CDSS document, Jul 22, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.