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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600532
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:57:53 PM

Document Has Been Signed on 04/05/2023 02:57 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 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:
04/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lydia Alvarez, Care Staff TIME COMPLETED:
03:00 PM
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On 4/05/23 at 2:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit to deliver appeal rights. LPA met with Lydia Alvarez, Care Staff and explained the purpose of the visit.

On 4/03/23 LPA issued 2 deficiencies to the facility. LPA is at the facility on this date to provide facility with a copy of their appeal rights.

Appeal rights printed, exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2023
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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