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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340310833
Report Date: 03/21/2024
Date Signed: 03/21/2024 02:30:08 PM

Document Has Been Signed on 03/21/2024 02:30 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 11DATE:
03/21/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Crisina JacksonTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on evictions initiated for two residents of this facility. LPA Moleski met with facility administrator Crisina Jackson and explained the purpose of the visit.

LPA Moleski reviewed an eviction noticed dated March 11, 2024 for a resident (R1). R1's eviction notice was not valid. Jackson agreed to rescind the eviction notice.

LPA Moleski reviewed an incident report dated 3/17/24 which stated that an eviction would be initiated for R2. LPA Moleski reviewed an eviction notice for R2. This eviction notice was valid and shall remain in effect. LPA Moleski reviewed this facility's house rules. LPA Moleski provided technical assistance regarding eviction procedures during this visit.

LPA Moleski reviewed an eviction notice for a resident (R3) at another facility operated by Jackson. LPA Moleski informed Jackson the notice would need to be revised and resent to the resident.

No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Jackson.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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