Community Care Licensing

Document Has Been Signed on 09/03/2021 03:10 PM - It Cannot Be Edited

FACILITY NAME:	JACKSON HOUSE TEMECULA		FACILITY NUMBER:	331880806
ADMINISTRATOR:	SOPHIA MORELLI		FACILITY TYPE:	772
ADDRESS:	28999 OLD TOWN FRONT ST. #101		TELEPHONE:	(951) 261-8392
CITY:	TEMECULA	STATE: CA	ZIP CODE:	92590
CAPACITY: 16		CENSUS: 8	DATE:	09/03/2021
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Patrick Zierman, CEO/Sophia Morelli, Adminstrator		TIME COMPLETED:	01:30 PM

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An Informal Meeting was conducted today virtually via Microsoft Teams to discuss a recent incident that took place at the facility. Present at today’s meeting were: Licensing Program Manager Joel Esquivel, Acting Licensing Program Manager Tricia Danielson and Licensing Program Analyst, Yolanda Delgado. During today’s conference, the following matter was discussed: The ability of the C1 to obtain a sharp object and cause harm to self. Pre-assessment of clients prior to admit for the facility. Processes to relay to staff in regards to new admits. The facility's staff to client ratio. The assurances in place to prevent an incident in this nature from happening again. The re-training of all staff for health and safety checks at the facility. Mr. Zierman informed the department that he understands his roles and responsibilities in the health and safety of the clients. Mr. Zierman is interested in the Technical Support Program that is offered through DSS, referral will be made by LPA Delgado. An exit interview was conducted where this report was discussed and provided to the licensee. LPA emailed copy of the report for signature and requested the sign copy to be emailed back. Licensee agrees. Signed LIC809.pdf

SUPERVISORS NAME: Efren Malagon LICENSING EVALUATOR NAME: Yolanda Delgado LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021