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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604232
Report Date: 12/30/2021
Date Signed: 12/30/2021 04:52:30 PM

Document Has Been Signed on 12/30/2021 04:52 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JACKSON HOUSE EL CENTROFACILITY NUMBER:
134604232
ADMINISTRATOR:CAROLINA NUNEZ-GARCIAFACILITY TYPE:
772
ADDRESS:2364 SOUTH 2ND STREETTELEPHONE:
(760) 237-9769
CITY:EL CENTROSTATE: CAZIP CODE:
92243
CAPACITY: 16CENSUS: 8DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Counselor, Carolina RivasTIME COMPLETED:
12:28 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno conducted an unannounced Required 1 - Year Visit. LPA was greeted by Receptionist, Ida Fernandez. LPA met with Counselor Carolina Rivas, identified herself, and discussed the purpose of the visit. All staff present have a current criminal record clearance.

LPA conducted a tour with Counselor Rivas. In accordance with the Department’s Infection Control program, LPA provided technical assistance and observed and evaluated the facility's implementation of their COVID-19 Mitigation Plan (LIC 808).

LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of PPE (Personal Protective Equipment). Based on observations, the facility is in compliance with and has implemented infection control practices as outlined in its Mitigation Plan (LIC 808).

No deficiencies were observed during today's visit. An exit interview was conducted with Counselor, Rivas. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail to Administrator Carolina Nunez-Garcia. Email receipt confirmation will confirm receipt of this report.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Marisela Garcia-Centeno
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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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