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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600045
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:59:06 PM

Document Has Been Signed on 04/25/2023 04:59 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: 4DATE:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Evelyn Marquez-Uy/AdministratorTIME COMPLETED:
04:55 PM
NARRATIVE
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On this day, April 25, 2023, at 11:45 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Mary Grace Rentoria. LPA informed the reason for visit. LPA met with Evelyn Marquez, administrator, after several minutes. LPA also met with other staff, Lydia Alvarez. All these staff were fingerprinted, and associated to the facility.

LPA inspected the facility inside and out including but not limited to living room, dining area. kitchen, bedrooms, bathrooms, laundry area, staff rooms, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Fire extinguishers were observed fully charge with tags showed serviced February 2, 2023. Facility has 2 in 1 carbon monoxide and smoke detector that was observed operational. Hot water temperature in the common bathroom was tested. Facility conducts fire drills monthly, and records showed last conducted April 19, 2023.

LPA reviewed 4 residents and 5 staff files, and interviewed 2 residents and 2 staff. Medications were checked and compared with records. Storage for medications and sharps were observed locked.

LPA observed the following:
-at 12:11 pm, expired macaroni salad (expiration: 4/17/23)
-at 12:18 pm, hot water temperature at 139.8 degrees Fahrenheit
-at 12:22 pm, uneven surface between the wood flooring and cement ground area in the backyard. According to administrator the contractor is scheduled to come back to finish the job.
-at 2:50 pm, residents' records of cash resources not complete for all residents.
-at 3:00 pm, administrator was interviewed who stated facility does not maintain LIC622 Centrally Stored Medication and Destruction Record.
-at 3:15pm, 3 out of 4 residents are over 60 years of age
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JACKSON HOUSE III
FACILITY NUMBER: 015600045
VISIT DATE: 04/25/2023
NARRATIVE
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Administrator to submit the following updated documents by May 9, 2023:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. LIC9282 Infection Control Plan
4. Proof of Surety Bond coverage

LPA verified, and according to Evelyn Marques-Uy stated she took over the administrator position years ago. Licensee to submit the following by May 2, 2023:
1. Signed letter indicating the change of administrator with effective date.
2. Copy of Evelyn Marquez-Uy's LIC501 Personnel Record and administrator certificate (# 6032655735; expiration: 10/12/24).

Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed with the administrator.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/25/2023 04:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/25/2023 at 03:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JACKSON HOUSE III
FACILITY NUMBER: 015600045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for hot water temperature at 139.8 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Administrator to adjust the temperature and submit proof by 4/26/23.
Type A
Section Cited
CCR
80076(a)(1)
80076 Food Services
(a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above for expired macaroni salad which poses an immediate health and personal rights risks to persons in care.
POC Due Date: 04/26/2023
Plan of Correction
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Admiinistrator to have all the food supplies checked and in-service the staff. Proof to be submitted by 4/26/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 04:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/25/2023 at 04:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JACKSON HOUSE III
FACILITY NUMBER: 015600045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care.....

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for not having a complete record of residents' cash resources which poses personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Administrator to complete the records and submit self-certification by 5/09/23.
Type B
Section Cited
CCR
80075(k)(7)(AtoH)
80075 Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
(A)to(H)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for not completing LIC622 Centrally Stored Medication and Destruction Record for all residents which poses a potential health, and personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Administrator to complete an LIC622 for all residents and submit self-certification by 5/09/23.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 04:59 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 04/25/2023 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JACKSON HOUSE III
FACILITY NUMBER: 015600045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
85068.4 Acceptance and Retention Limitations
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for 3 out of 4 residents over 60 years old which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Administrator stated she'll submit age exception request. Copies of supporting documents including but not limited to the following by 5/09/23: 1) Appraical/Needs and Services Plan; 2) Physician's Report; 3) Letter of support from resident's case manager
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023


LIC809 (FAS) - (06/04)
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