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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880806
Report Date: 12/21/2023
Date Signed: 12/21/2023 05:02:19 PM

Document Has Been Signed on 12/21/2023 05:02 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
RIVERSIDE ASC, 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: 8DATE:
12/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:06 PM
MET WITH:Business Office Manger, Sheri HolmeslyTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the facility in order to conduct a case management. LPA met with Business Office Manager Sheri Holmesly who was informed of the purpose of the visit. There were (8) residents and (9) staff during the visit.

The visit was initiated to conduct a confirmation of removal for Staff #1 (S1) after the regional office received letter on exemption denial. A health and safety check was conducted on the facility residents. LPA conducted interviews, conducted a tour of the facility, and obtained records during the visit.The facility personnel report was verified and all staff have a cleared background.

LPA observed construction in the facility and was informed facility laundering equipment would be repaired 12/22/2023. Due to time constraints additional visits or deficiencies may be conducted.

An exit interview was conducted with Business Office Manger, Sheri Holmesly where this report was reviewed and provided to them.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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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