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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600045
Report Date: 09/06/2024
Date Signed: 09/11/2024 02:30:47 PM

Document Has Been Signed on 09/11/2024 02:30 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/
DIRECTOR:		EVELYN MARQUEZ UYFACILITY TYPE:
735
ADDRESS:3212 SAN ANDREASTELEPHONE:
(510) 563-5140
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY: 6CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Evelyn Marquez UyTIME VISIT/
INSPECTION COMPLETED:
02:45 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 10:10 am, Licensing Program Analysts (LPAs) Luisa Fontanilla arrived unannounced to conduct an annual required inspection and met with Administrator Evelyn Marquez Uy. LPA explained to the Administrator the purpose of the visit.

During the visit, LPA with Administrator inspected the facility inside and out including but not limited to client bedrooms, bathrooms, dining area, kitchen and garage. The facility is a Level 4i vendored by the Regional Center of the East Bay (RCEB). All clients were at their respective day programs.

Hot water measured at 117.7 Fahrenheit. There was sufficient supply of perishable and non perishable foods. No bodies of water were observed. Hallways and passageways were observed free of obstruction.

At 11:05 am, LPA reviewed 4 client files and 4 staff files. All staff are fingerprint cleared and associated to the facility. Staff have current First aid and CPR training. At 11:50 am, LPA reviewed P&i money and log. Last fire drill was conducted on 8/11/2024 and last earthquake drill was done on 8/11/2024. Smoke detectors and carbon monoxide were tested and observed operational. Fire extinguisher that appeared full and was last serviced on 2/28/2024 was observed in the kitchen. First aid kit was observed complete. At 1pm, LPA reviewed Medication Administration Record (MAR) and medicines with the Administrator. .

The following deficiencies were observed:
  • a pair of scissors was observed unlocked in the kitchen drawer
  • facility does not have window screens
  • facility does not have a container to dispose diabetes lancets

continuation on Lic 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 5
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: 09/06/2024
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
26
27
28
29
30
31
32
The following records were requested to be submitted to CCL by Monday, September 16, 2024:
  • Lic 500
  • Lic 9020
  • Surety bond
  • Liability Insurance
  • Vehicle registration/insurance/driver's license
  • Lic 610D


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

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 09/11/2024 02:30 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/11/2024 at 02:14 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 pair of scissors unlocked in the kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/11/2024
Plan of Correction
1
2
3
4
During the visit, the Administrator locked scissors. This deficiency is cleared during the visit.
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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/11/2024 02:30 PM - It Cannot Be Edited


Created By: Luisa Fontanilla On 09/11/2024 at 02:14 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: 09/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(3)(B)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (3) All staff who are assigned to assist clients with the self-administration of injectable medication shall observe the following procedures:  (B) A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observaiton, the licensee did not comply with the section cited above in not having an appropriate disposal container for lancets which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
1
2
3
4
The Administrator will purchase the appropriate container for needles/lancets and send photo proof to CCL by POC date.
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 not having window screens which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
1
2
3
4
BY POC date, the Administrator will install window screens, take photos and send photos to CCL by POC date.
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: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5