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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310833
Report Date: 09/24/2021
Date Signed: 09/24/2021 03:29:33 PM

Document Has Been Signed on 09/24/2021 03:29 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JACKSON'S FACILITYFACILITY NUMBER:
340310833
ADMINISTRATOR:CORAZON BUANFACILITY TYPE:
735
ADDRESS:637 WILSON AVENUETELEPHONE:
(916) 532-7078
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 12CENSUS: 12DATE:
09/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Levy TilanoTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 09/24/2021 at 8:15 AM. LPA met with Levy Tilano and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds current administrator certificate and expires on 12/04/2022. The facility is licensed for twelve ambulatory residents. There are currently 12 residents who reside at this facility.

LPA Martinez toured the facility with Levy Tilano on 09/24/2021 at 9:00 AM.

The facility has one main entry screening point, which includes a sign in sheet. All employees, visitors, and essential workers are screened before entering the facility. The facility has a designated outdoor area for visits. The facility has Covid-19 posting throughout the facility. The facility has submitted a Covid-19 mitigation plan to CCLD. The facility has a 30 day supply of PPE, and facility staff have received donning and doffing training. The facility has hand sanitizer throughout the facility.

The facility furniture is spaced 6 feet apart. Moreover, the facility is sanitary. In addition, the facility conducts disinfecting cleaning twice a day, and disinfects high touch common surfaces after use. The facility has a designated lead infection control employee.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time.


An exit interview was conducted, and a copy of this report was given to the facility at the end of this visit.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 09/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2021
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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