340310833-2-19-2025-27-AS-KHOS-DEVHUH-20250318063019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340310833
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:52:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2024 and conducted by Evaluator Holly Williams

COMPLAINT CONTROL NUMBER: 27-AS-20241223090118

FACILITY NAME:	JACKSON'S FACILITY		FACILITY NUMBER:	340310833
ADMINISTRATOR:	CORAZON BUAN		FACILITY TYPE:	735
ADDRESS:	637 WILSON AVENUE		TELEPHONE:	(916) 532-7078
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95833
CAPACITY:	12	CENSUS: 10	DATE:	02/19/2025
		UNANNOUNCED	TIME BEGAN:	02:47 PM
MET WITH:	Crisina Jackson		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff falsify documents.
Staff mismanage residents' medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Holly Williams arrived unannounced to deliver findings on this complaint investigation. LPA Williams met with Crisnia Jackson and explained the purpose of the visit.

This investigation consisted of record review and interviews with staff and residents.

In an interview, Jackson stated the pharmacy stated on the bubble pack that the pill should be taken in the bedtime evening and they were confused and there was only one pill. In an interview, Jackson said they called pharmacist and the pharmacist said they put it for bedtime because it makes the resident sleepy. There was no issue accept the aforementioned one and they took care of it with the Pharmacist the same day.
LPA Williams reviewed several of the clients Medication Administration Records (MAR) at the Jackson's Facility and all were up to date.
[Continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20241223090118

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JACKSON'S FACILITY	FACILITY NUMBER: 340310833
	VISIT DATE: 02/19/2025

NARRATIVE

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R1-R7 all stated that they have not had any issues with their medication.
LPA Williams interviewed S1, a caregiver and cleaner for the facility. S1 stated that she has seen medication given on time with no problems.

Based on interviews, observation, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Jackson.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Holly Williams	TELEPHONE: 916-798-3161
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC9099 (FAS) - (06/04)

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