<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600045
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:40:54 PM

Document Has Been Signed on 08/24/2023 04:40 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:EVELYN MARQUEZ UYFACILITY TYPE:
735
ADDRESS:3212 SAN ANDREASTELEPHONE:
(510) 563-5140
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Mary Grace RentoriaTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On this day at around 2 PM, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with staff Mary Grace Rentoria. Administrator Evelyn Uy was not available but was informed about the visit by telephone.

The facility is a Level 4 home vendored by the Regional Center of the East Bay (RCEB). The facility has an approved fire clearance for all ambulatory clients only.

LPA inspected the facility inside and out including but not limited to client rooms, dining area, bathrooms, kitchen and backyard. Hot water in the kitchen measured at 120 degrees Fahrenheit.

The following deficiencies were observed:
  • both passageways were observed with empty boxes, garbage bins and wood planks
  • refrigerators were observed with food spills and freezer with strong odor
  • refrigerator temperature in the garage was observed at 79.9 degrees Fahrenheit
  • chain saw observed unlocked in the backyard


Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).

Exit interview was conducted and Appeal Rights was provided to Rentoria.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/24/2023 04:40 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/24/2023 at 03:33 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having empty boxes, garbage bins and wood planks in left and right side passageways which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
1
2
3
4
Administrator will remove all objects in both passageways, take pictures of cleared passageways and send proof to CCL by POC date.
Type B
Section Cited
CCR
85076(d)(3)
Food Service
(3) Refrigerators shall be large enough to accommodate required perishables and shall maintain a maximum temperature of 45 degrees F (7.2 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having refrigerator in the garage temperature measured at 77.9 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
1
2
3
4
By POC date, Administrator states refrigerator will be discarded and notify CCL.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/24/2023 04:40 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/24/2023 at 03:33 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(4)
Food Service
(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation , the licensee did not comply with the section cited above in having refrigerator with food spills, rotten lemon which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
1
2
3
4
Administrator will get refrigerator clean up and submit photo proof by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/24/2023 04:40 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 08/24/2023 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: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having a chain saw unlocked in the back yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/24/2023
Plan of Correction
1
2
3
4
Staff locked chainsaw during visit. Deficiency is cleared.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4