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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440656
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:03:49 AM

Document Has Been Signed on 01/26/2023 10:03 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JACKSON HOUSEFACILITY NUMBER:
011440656
ADMINISTRATOR:JACKSON, WARDELL D.FACILITY TYPE:
735
ADDRESS:950 - 92ND AVENUETELEPHONE:
(510) 639-7114
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 6CENSUS: 5DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Alan Knowles, ManagerTIME COMPLETED:
10:15 AM
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On 1/26/2023 at 9:15 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. LPA met with Manager, Alan Knowles and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with including but not limited to front entrance, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2 day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily.
Bathrooms are equipped with liquid soap, paper towel and trash bins. Facility staff were observed to be wearing proper PPE. Facility has a 30 day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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