<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600532
Report Date: 12/10/2025
Date Signed: 12/10/2025 05:32:14 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
09/17/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250917084942
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: 4DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Wardell Jackson, AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide activities for resident.
Facility has expired foods.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2025 at 12:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with staff, Laura Valentine and informed her the reason for visit. Administrator, Wardell Jackson arrived an hour later.

During the course of investigation, LPA interviewed 4 staff, 3 clients, 4 witnesses, and complainant. LPAs reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, individual program plan (IPP), and emergency information.

Staff do not provide activities for resident.
Interview with staff indicated that clients have toys and would take clients out for walks. However, LPAs observed no activities were provided to clients during visits on 9/22/2025 and 12/10/2025. LPAs observed clients were sitting in the living room without music or other activities.
(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
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 5
Control Number 15-AS-20250917084942
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
VISIT DATE: 12/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility has expired foods.
LPAs observed facility had large amounts of expired non-perishable food supplies during visit on 9/22/2025. There was about 4-5 bags full of expired food.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted with Wardell Jackson. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250917084942
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: 12/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2025
Section Cited
CCR
80076(a)(1)
1
2
3
4
5
6
7
Food Services. (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Staff threw away all the expired foods during inspection on 9/22/2025. Administrator has agreed to create a written plan to manage food supplies.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having large amounts of expired foods which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
Administrator will submit written plan to CCLD by POC date.
Type B
12/22/2025
Section Cited
CCR
85079(a)
1
2
3
4
5
6
7
Activities. (a) The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients... This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to create a written plan for conducting activities for clients and submit written plan to CCLD by POC date.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by not providing activities to clients which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
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: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/17/2025 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250917084942

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: 4DATE:
12/10/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Wardell Jackson, AdministratorTIME COMPLETED:
05:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not provide adequate supervision to resident.
Staff left residents in soiled diaper for extended period of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2025 at 12:00PM, Licensing Program Analysts (LPAs) G. Luk and Y. Brown arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with staff, Laura Valentine and informed her the reason for visit. Administrator, Wardell Jackson arrived an hour later.

During the course of investigation, LPA interviewed 4 staff, 3 clients, 4 witnesses, and complainant. LPAs reviewed and obtained documents including staff roster with contact information, staff schedule, physician's report, individual program plan (IPP), and emergency information.

Staff do not provide adequate supervision to resident.
LPAs observed staff schedule indicates there are 2 staff working during the morning and afternoon shifts, and 1 staff working during night shift. Interview with staff revealed there are 2 staff working during the morning and afternoon shifts. There were 2 staff providing care and supervision for clients during visits on 9/22/2025 and 12/10/2025.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20250917084942
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
VISIT DATE: 12/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff left residents in soiled diaper for extended period of time.
Interview with staff indicated that they check on clients every 15-20 minutes for incontinence care. Staff stated there were no incidents where clients were in soiled diapers for an extended period of time and staff would change client's diaper when it becomes soiled. Interview with witnesses revealed that staff would change client's diaper prior to attending day program.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Wardell Jackson. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5