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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880806
Report Date: 02/15/2024
Date Signed: 02/15/2024 02:49:13 PM

Document Has Been Signed on 02/15/2024 02:49 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: 12DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:ADMINISTRATOR, SHANTE OGDENTIME COMPLETED:
02:58 PM
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On February 15, 2024, Licensing Program Analyst (LPA), Venus Mixson arrived at the Social Rehabilitation Facility unannounced to conduct the required annual inspection. LPA Mixson met with the Administrator, Shante Ogden, introduced herself, and stated the purpose of the visit. The File review was conducted in the office and additional forms were requested and reviewed on site.

LPA Mixson toured the facility, along with the Sheri, and inspected the inside and outside of the facility. The facility is a two-story building located at 28999 Old Town Front Street Temecula, CA. 92590. The facility phone number is (951) 261-8392 and it is operable.
Physical Plant: The physical plant, is in good condition, neat, and orderly. Outdoor and indoor passageways are free of obstruction at the time of this visit. The Facility activity rooms have the required furniture, such as tables, chairs, storage space, and sufficient lighting. The building temperatures throughout was per regulations. The activity rooms are equipped with the required items, per Title 22. The hot water temperature tested within the range required for regulations. The restrooms were equipped with liquid soap and paper towels. The facility had activity schedules posted, along with Fire Drills, and available for review. The Facility has emergency food and water. LPA Mixson inspected the common areas. The fire extinguishers were in the green and the program recently had fire inspection. Carbon monoxide alarms, along with smoke detectors were observed. There was a locked and centralized storage area for medications. The Facility had a designated area for hard copy of staff files, and it was locked. The residents’ files were maintained online. Emergency disaster plans, personal rights, and complaint procedures were posted in a prominent area. There was adequate seating in the common areas and sufficient space for activities. LPA Mixson reviewed staff and resident files and conducted staff and resident interviews. There were no regulation violations observed during today’s visit. An exit interview was conducted, and a copy of this report was provided to the Administrator, Shante Ogden.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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