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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600532
Report Date: 02/16/2023
Date Signed: 02/16/2023 03:00:02 PM

Document Has Been Signed on 02/16/2023 03:00 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
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:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Wardell Jackson, AdminstratorTIME COMPLETED:
03:15 PM
NARRATIVE
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On 2/16/2023 at 12:15 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct an annual Infection Control Inspection. Upon arrival LPA was greeted by a Cargiver, Caregiver stated their name was "James". Administrator, Wardell Jackson arrived around 12:40 PM, LPA greeted them and explained the purpose of the visit.

During the Infection Control Inspection, LPA toured facility with including but not limited to front entrance, hand washing stations, bedrooms, common areas, kitchen, and backyard. Facility has a sufficient 2 day perishable and 7 day non-perishable food supply. Thermometer and hand sanitizer were observed. Hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bins with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan and maintains record of routine screening for residents and staff. Smoke and carbon monoxide detectors were observed and maintained. First Aid kit was complete. Fire extinguisher was observed serviced. LPA observed facility passages inside and out free of obstruction.

The following deficiency was observed during inspection:
-At approximately 12:30 PM LPA observed Staff 1( S1) was not associated to the facility nor did they have a criminal clearance. A civil penalty of $100 is being assessed today.

The following deficiency were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties

Exit interview conducted and a copy of this report provided along with Appeal rights.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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 02/16/2023 03:00 PM - It Cannot Be Edited


Created By: Paris Watson On 02/16/2023 at 02:17 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 IV
FACILITY NUMBER: 015600532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by having S1 work at the facility without being associated nor having a criminal clearance which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty of $100 is being assessed today.
POC Due Date: 02/17/2023
Plan of Correction
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Admistrator will have S1 completed a criminal clerance and associate S1 to facility. Administartpr will send proof to CCLD by POC date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Paris Watson
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2023


LIC809 (FAS) - (06/04)
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