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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600045
Report Date: 04/21/2023
Date Signed: 04/21/2023 05:22:51 PM

Document Has Been Signed on 04/21/2023 05:22 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:
04/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Solange Aboke, StaffTIME COMPLETED:
05:30 PM
NARRATIVE
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On 4/212023 at 4:00PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit in regards to death report received on 4/7/2023. LPA met with staff, Solange Aboke and explained the purpose of the visit. LPA spoke with Administrator, Evelyn Marquez-Uy and stated she was not able to be at the facility. Administrator stated that staff is able to sign licensing reports.

LPA received death report on 4/7/2023 for client (C1). Death report revealed that at around 9:55PM, overnight staff (S2) heard C1 making strange sounds and observed C1 was restless. C1 started shaking and still restless. 911 was called. When paramedics arrived, CPR was performed for over 30 minutes. C1 passed away on 4/5/2023.

LPA interviewed 1 staff and was informed that S2 heard C1 making sounds and called S1. C1 was conscious and moving when S1 came in the room after getting S2's call. 911 was called right away. Police arrived first followed by paramedics shortly after.

LPA may return on a later date.

At 4:10PM, LPA request to review C1's files. However, staff did not have access to client's files. Administrator informed LPA that staff does not have the key to the office where the client files were kept.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.
Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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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Document Has Been Signed on 04/21/2023 05:22 PM - It Cannot Be Edited


Created By: Grace Luk On 04/21/2023 at 05:10 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2023
Section Cited
CCR
80070(d)

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Client Records. All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
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Administrator has agreed to submit a written plan to CCLD by POC date. Written plan should include future plans to make records available to CCLD.
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Based on observation, licensee did not comply with the section cited above by not having client records available which poses a potential health and safety risk to the persons in care.
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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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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