<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 05:43:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/05/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251205094241
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:Laura Valentine, Caregiver TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not conduct facility disaster drills as required
Staff did not ensure that complete client records were maintained at the facility
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) Y. Brown and G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Caregiver Laura Valentine and informed her the reason for visit. Administrator, Wardell Jackson arrived to the facility at 10:38 AM.

During the course of investigation, LPAs interviewed three (3) staff members and the complainant. LPAs reviewed documents such as (admission agreement, emergency information, care plan, physician's reports, and disaster drills.)

Continued on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
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-20251205094241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/17/2025
Section Cited
HSC
1565(c)
1
2
3
4
5
6
7
ยง1565 (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 [...] the names of staff participating in the drill.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
By POC date, the Administrator has agreed conduct a fire drill and maintain a log and submit proof of this fire drill log to CCLD.
8
9
10
11
12
13
14
Based on file review and interviews, licensee did not comply with the section cited above not having any fire drills conducted quarterly which poses a potential health and safety risk to the persons in care.
8
9
10
11
12
13
14
Civil penalty of the amount of $250 is being assessed for repeat violation.
Type B
12/17/2025
Section Cited
CCR
80070(a)
1
2
3
4
5
6
7
80070 Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By POC date, the Administrator agrees to review the regulation 80070(a) and submit a self-certification that the regulation has been reviewed and facility will abide by the regulation. Self-certification shall be submitted to CCLD.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above in having missing required forms in C1, C2, C3, and C4's file which poses a potential health and personal rights risks to 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: Yasamin Brown
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: 2 of 5
Control Number 15-AS-20251205094241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
Allegation: Staff did not conduct facility disaster drills as required
Finding: Substantiated

A review of the facilities disaster drill log indicated unclear indication of the most accurate date that a quarterly fire drill was conducted. During record review, LPAs observed that the fire drill log had been white out so there was not an accurate date shown. Interviews with staff revealed that the last fire drill was conducted some time last year but there has not been a recent drill conducted at the facility.

Allegation: Staff did not ensure that complete client records were maintained at the facility
Finding: Substantiated

During record review, LPAs observed that some client records were not maintained at the facility and were located at a different location. Interview with the Administrator revealed that some of the client records are maintain at a home office nearby therefore during the visit, LPAs were not able to obtain those documents. Interviews with the staff revealed that they do not have access to the client's records.

Based on LPAs 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, Division 6, Chapter 8), are being cited on the attached LIC9099D.

Exit interview was conducted with Wardell Jackson and Appeal Rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
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: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
12/05/2025 and conducted by Evaluator Yasamin Brown
COMPLAINT CONTROL NUMBER: 15-AS-20251205094241

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:Laura Valentine, Caregiver TIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not keep client medications in their original bottle
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2025 at 12:00 PM, Licensing Program Analysts (LPAs) Y. Brown and G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with caregiver Laura Valentineand informed her the reason for visit. Adminsitrator, Wardell Jackson arrived to the facility at 10:38 AM.

During the course of investigation, LPAs interviewed three (3) staff members and the complainant. LPAs reviewed documents such as (admission agreement, emergency information, care plan and physician's reports.)

Continued on LIC9099-C.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
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-20251205094241
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
Continued from LIC9099.

Allegation: Staff did not keep client medications in their original bottle
Finding: Unsubstantiated

During observation and record review, LPAs observed that medications were placed in their original prescribed bubble packs from the pharmacy. LPAs observed that the medications were not pre-dispensed or placed in different containers. Interview with staff revealed that the medication is dispensed from the prescribed bubble packs from the pharmacy and place in a cup or napkin for the clients to take.

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

No deficiencies are being cited on this date.

Exit interview conducted with Wardell Jackson and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Yasamin Brown
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