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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880806
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:58:35 PM

Document Has Been Signed on 02/18/2025 02:58 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/
DIRECTOR:		SHANTE OGDENFACILITY TYPE:
772
ADDRESS:28999 OLD TOWN FRONT ST. #101TELEPHONE:
(951) 261-8392
CITY:TEMECULASTATE: CAZIP CODE:
92590
CAPACITY: 16CENSUS: 15DATE:
02/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Office Manager, Sheri HolmeslyTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 2/18/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the social rehabilitation facility to conduct a required annual inspection. LPA was greeted and granted entry by Office Manager (OM), Sheri Holmesly who was informed of the purpose of the visit. Administrator, Shante Shirey was available over the phone and also informed of the purpose of LPA's visit. LPA reviewed the facility's Fire Safety Inspection Request (STD. 850) dated 6/19/2024, noting a fire clearance was granted for 12 ambulatory clients and four (4) non-ambulatory clients.

LPA toured the facility with Lead Nurse, Brian Caasi. During the tour, LPA observed building suites 102, 104, and 106 are designated as the residential program living quarters while the administrative offices are located in building suite 101. The facility is made up of eight bedrooms, two bathrooms, a kitchen, dining room, living room and computer area available for client use. Each bedroom has two twin beds and appropriate furniture and lighting. Each bathroom has two individual toilet stalls, two individual shower stalls and two sinks. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and seven-day supply of non-perishable foods, which are stored in a safe and healthful manner. LPA observed knives and sharp instruments secured in a locked kitchen drawer. Medications are secured in a locked cart inside the locked medication room. LPA observed charged fire extinguishers mounted throughout the facility last serviced on 6/19/2024. LPA also observed fire alarm systems and sprinklers throughout the facility. LPA reviewed random digital client files, which had updated needs and services plans and signed admission agreements. No bodies of water were observed on the premises. Indoor and outdoor pathways were free of obstructions. Outdoor shaded seating/smoking area is available for the clients in care. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to OM Holmesly.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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