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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600532
Report Date: 12/31/2024
Date Signed: 12/31/2024 04:43:31 PM

Document Has Been Signed on 12/31/2024 04:43 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JACKSON HOUSE IVFACILITY NUMBER:
015600532
ADMINISTRATOR/
DIRECTOR:		JACKSON, WARDELL D.FACILITY TYPE:
735
ADDRESS:14416 COLGATE STREETTELEPHONE:
(510) 563-5140
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 6CENSUS: 4DATE:
12/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator Wardell JacksonTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On 12/31/2024 at approximately 8:00 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct the Required Annual Inspection of the facility. Upon arrival, LPA stated the purpose of the visit to Caregiver Lydia Alvarez. Administrator Wardell Jackson arrived at approximately 9:30 AM.

The LPA inspected the facility inside and outside. All outdoor and indoor passageways were free of obstruction. Outside, there were no bodies of water. Inside, the temperature was 73.3 degrees Fahrenheit and the hot water temperature was 119.4 degrees Fahrenheit. The LPA observed adequate lighting in all of the rooms for the comfort and safety of the individuals. The LPA observed more than the minimum of 7 days of nonperishable food. There was no edible perishable food until the Administrator arrived and opened the locked storage building in the backyard. Sharps and other dangerous items were stored inaccessibly to residents. Smoke and carbon monoxide detectors were in operating condition. Fire extinguishers observed to be fully charged and last serviced on 12/4/2024.

The LPA reviewed the records of 4 consumers and 5 staff members.

6 B-Type citations issued (refer to LIC 809-D for details).

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 12/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 12/31/2024 04:43 PM - It Cannot Be Edited


Created By: James Sampair On 12/31/2024 at 03:43 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: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The best buy date on a bag of carrots was 4/24/2024, more than 6 months beyond the best buy date. Long roots were growing out of the carrots, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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Corrected during inspection.
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. 2 days of fresh perishable food was not present in the facility and caregivers did not have a key to open the storage building where fresh perishable food was stored, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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The Administrator did bring in fresh perishable food from the locked storage building when he arrived. On or before the due date, the Administrator will provide a set of keys to give caregivers access to all 3 of the locked storage buildings.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/31/2024 04:43 PM - It Cannot Be Edited


Created By: James Sampair On 12/31/2024 at 03:43 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: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(2)
Food Service
(2) Freezers shall be large enough to accommodate required perishables and shall be maintained at a temperature of zero degrees F (-17.7 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the freezer in the kitchen than was 40 degrees Fahrenheit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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On or before the due date, the Licensee shall send proof to the LPA that the temperature in all 3 freezers has been reduced to zero degrees or lower. The Licensee shall also purchase a thermometer to stay at the facility for staff to measure the temperature now and in the future.
Type B
Section Cited
CCR
85076(d)(4)
Food Service
(4) Freezers and refrigerators shall be kept clean, and food storage shall permit the air circulation necessary to maintain the temperatures specified in (2) and (3) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the refrigerator / freezer in the kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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On or before the due date, the Licensee shall send proof to the LPA that all 3 refrigerators and/or freezers have been thoroughly cleaned.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/31/2024 04:43 PM - It Cannot Be Edited


Created By: James Sampair On 12/31/2024 at 03:43 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: 12/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having no LIC 610D or a comprehensive Emergency/Disaster Plan at the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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On or before the due date, the Licensee shall send a LIC 610D with Yard Sketch with Assembly Point to the LPA.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by having no proof of quarterly drills, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/07/2025
Plan of Correction
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On or before the due date, the Licensee shall send proof to the LPA that the Emergency/Disaster drills had been done at least quarterly for every shift during 2024. If they had not been done, then they shall send proof that one has been conducted and their schedule for running them quarterly during 2025.
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:Harpreet Humpal
LICENSING EVALUATOR NAME:James Sampair
LICENSING EVALUATOR SIGNATURE:
DATE: 12/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4