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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600532
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:39:38 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: DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are mismanaging residents' medications.
INVESTIGATION FINDINGS:
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On 4/21/23 at 2:10 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings in regard to the allegation above. LPA met with Lydia Alvarez and explained the purpose of the visit. LPA also spoke to Licensee Wardell Jackson on the telephone.

At 2:00 p.m. on 4/2/23, LPA observed that medications were pre-poured into paper cups to be administered at later times today.

This agency has investigated the allegation above. We have found that the allegation is substantiated. Based on LPA's observations the preponderance of evidence standard has been met, therefore the above allegation is 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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 2
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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited
CCR
80075k(5)
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80075 Health Related Services:
(k) The following requirements shall apply
(5) Each client's medication shall be stored in its originally received container.
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Licensee has agreed to store and administer medications according to regulation and submit a plan to CCL by POC date.
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Based on observation, licensee failed to keep medications stored in their original containers by pre-pouring medications into paper cups.
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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: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2