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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880806
Report Date: 02/28/2023
Date Signed: 02/28/2023 02:24:59 PM

Document Has Been Signed on 02/28/2023 02:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACKSON HOUSE TEMECULAFACILITY NUMBER:
331880806
ADMINISTRATOR:SHANTE OGDENFACILITY TYPE:
772
ADDRESS:28999 OLD TOWN FRONT ST. #101TELEPHONE:
(951) 261-8392
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 16CENSUS: 13DATE:
02/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Shante Ogden, Administrator TIME COMPLETED:
02:30 PM
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On February 28, 2023, Licensing Program Analyst (LPA), Chinwe Nwogene made an unannounced visit to the facility to conduct an annual inspection focused on infection control. LPA was greeted and granted entry into the facility by Administrator, Shante Ogden who was informed of the purpose of the visit. LPA was informed by Shante that facility currently has one positive Covid-19 case but the facility it following the CDC COVID-19 guidelines.

During today's visit, LPA toured the facility inside and out with Shante and made observations regarding the infection control measures that the facility has implemented. LPA observed Covid-19 postings posted throughout the facility. The facility has an adequate amount of hand hygiene supplies (soap, hand sanitizer and paper towels) in all restrooms. The facility has a plan in place to monitor residents regularly for any changes in condition, which includes daily temperature checks. The Facility will contact the resident’s physician should there be any event of COVID-19 related illnesses. The facility has a designated infection control lead. The facility also cleans and disinfects the highly touched surfaces during each shift, and as needed. LPA observed PPE supplies. No deficiencies noted at the time of visit.

An exit interview was conducted, and a copy of this report was reviewed with and provided to Shante Ogden.

SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Chinwe Nwogene
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2023
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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