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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600045
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:42:46 PM

Document Has Been Signed on 10/06/2022 03:42 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JACKSON HOUSE IIIFACILITY NUMBER:
015600045
ADMINISTRATOR:JACKSON, WARDELLFACILITY TYPE:
735
ADDRESS:3212 SAN ANDREASTELEPHONE:
(510) 563-5140
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 0DATE:
10/06/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Evelyn Marquez-Uy, AdministratorTIME COMPLETED:
03:55 PM
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On 10/6/2022 at 2:45PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen conducted an announced Case Management visit to inspection the facility after completion of repairs related to fire damages. LPAs met with Administrator, Evelyn Marquez-Uy.


LPAs observed no clients at the facility. LPAs toured the facility including but not limited to bedrooms, bathrooms, common areas, kitchen, garage, and outdoor areas. LPAs observed that the facility sketch does not match the current floor plan. Therefore, LPAs are requesting a new facility sketch from the licensee and administrator to be submitted by 10/13/2022. LPAs will request fire inspector to inspect the facility once new facility sketch is received.


No deficiencies are being cited on this date.


Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2022
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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