015600532-4-3-2023-15-AS-KHOS-CRFQ5E-20230502115144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600532
Report Date: 04/03/2023
Date Signed: 04/03/2023 02:53:18 PM

Unsubstantiated

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 IV		FACILITY NUMBER:	015600532
ADMINISTRATOR:	JACKSON, WARDELL D.		FACILITY TYPE:	735
ADDRESS:	14416 COLGATE STREET		TELEPHONE:	(510) 563-5140
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94579
CAPACITY:	6	CENSUS: 6	DATE:	04/03/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Lydia Alvarez, Care Staff		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff does not maintain facility clean and sanitary.
Staff does not ensure that facility is free from pests.
Staff does not ensure that residents' medications are locked.

INVESTIGATION FINDINGS:

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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. LPA observed the kitchen area to be clean and free of pests. Bedrooms, bathrooms, and common areas were also clean and in good repair. LPA also observed that there was a locked medication cabinet in the hallway outside one of the bedrooms.

This agency has investigated the allegations above. We have found that the allegations are unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

Unsubstantiated

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)

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