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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600532
Report Date: 04/03/2023
Date Signed: 04/21/2023 02:37:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/24/2023 and conducted by Evaluator Gregory Clark
COMPLAINT CONTROL NUMBER: 15-AS-20230324105604
FACILITY NAME:JACKSON HOUSE IVFACILITY NUMBER:
015600532
ADMINISTRATOR:JACKSON, WARDELL D.FACILITY TYPE:
735
ADDRESS:14416 COLGATE STREETTELEPHONE:
(510) 563-5140
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY:6CENSUS: 6DATE:
04/03/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Lydia Alvarez, Care StaffTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff does not ensure that facility has adequate food supplies.
Staff are mismanaging residents' medication administration records.
INVESTIGATION FINDINGS:
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***This is an amended report***On 4/03/23 at 1:15 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings in regard to the allegations above. LPA met with Lydia Alvarez and explained the purpose of the visit. LPA also spoke to Licensee Wardell Jackson and House Manager Henry Montgomery via telephone.

During the course of investigation, LPA toured facility including but not limited to: front entrance, bathrooms, bedrooms, common areas, kitchen and backyard. Facility does not have a sufficient 2-day perishable and one week non-perishable food supply. Food is kept in locked sheds in the backyard inaccessable to staff and residents.

***Report continues on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20230324105604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 IV
FACILITY NUMBER: 015600532
VISIT DATE: 04/03/2023
NARRATIVE
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***Report continues from LIC9099***

At 2:00 p.m., LPA reviewed the Medication Administration Records (MARs) and observed that there were no medications initialed as administered for April 1, 2 or 3, 2023.

This agency has investigated the allegations above. We have found that the allegations are substantiated. Based on LPA's observations the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.CCLD1515


Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230324105604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 IV
FACILITY NUMBER: 015600532
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited
CCR
80070(a)
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80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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Licensee has agreed to submit an plan for medication storage and proof of staff training to CCL by POC date.
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Based on the review of the clients medications logs. the LPA found no medications were signed off as being dispensed to clients for April 1, 2, 3, 2023 which poses an immediate safety risk to residents in care.
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Type B
04/05/2023
Section Cited
CCR
85076(d)(1)
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Food Service. Supplies of staple nonperishable foods for a minimum of one week...shall be maintained on the premises.
This requirement is not met as evidence by:
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Licensee has agreed to send a plan for food storage to LPA by POC date.
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Based on observation, licensee failed to keep a 2 day perisable and one week of non-perishable food supply at the facility which poses a potential health and safety risk to the clients 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3