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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340310833
Report Date: 03/29/2024
Date Signed: 03/29/2024 09:50:32 AM

Substantiated


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
02/29/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240229092940
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:
03/29/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Crisina JacksonTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Staff member yells in the presence of residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Crisina Jackson and explained the purpose of the visit.

This investigation consisted of interviews. LPA Moleski interviewed Jackson, three staff members (S1-S3), and 10 residents (R1-R10).

In an interview, S1 described an incident which occurred on February 22, 2024, wherein Jackson yelled at her staff due to a resident’s (R9’s) medications being sent from a pharmacy in separate packages. S1 said that this occurred in the living room area near the dining room, where several residents were sitting after dinner. In an interview, S2 described the same incident, and said that R2, R9, and R10 were present. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
02/29/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240229092940

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: DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Crisina JacksonTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff member does not ensure that resident's personal information remains confidential.
INVESTIGATION FINDINGS:
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9
10
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13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Crisina Jackson and explained the purpose of the visit.

This investigation consisted of interviews. LPA Moleski interviewed Jackson, three staff members (S1-S3), and 10 residents (R1-R10).

In interviews, S1 and S2 described an incident which occurred on February 22, 2024 wherein Jackson yelled at staff due to a resident’s (R9’s) medications being sent from a pharmacy in separate packages. Both S1 and S2 alleged that confidentiality of information was breached, but described the content of the disagreement involving Jackson to be primarily the manner in which medications were delivered. S3 did not recall any confidential information being discussed during this disagreement. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240229092940
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: 03/29/2024
NARRATIVE
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In interviews, R1-R3, and R6-R10 did not voice concerns about private or confidential information being shared in front of other residents. In an interview, R4 said staff spoke about medications in front of others, sometimes in English and sometimes in another language. In an interview, R5 said that people were “constantly” talking about medication, but could not provide details as to the context of these disclosures.

The department has determined the following as it relates to the allegation that a staff member does not ensure that resident’s personal information remains confidential:

Based on interviews, 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240229092940
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: 03/29/2024
NARRATIVE
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In an interview, S3 said that Jackson raises her voice if people ignore her speaking in a lower voice. S3 said Jackson occasionally yells at residents, and at S3. S3 recalled the incident described by S1 and S2, which was described as a “heated disagreement,” and said that there were residents in the facility who must have heard some of it.

In an interview, R1 said that Jackson “orders” people around. R2 said Jackson yells at people in the dining area, including R2 and others. R4 said that Jackson does yell at others, and will have a big reaction to a small thing. R4 said that Jackon yells at staff and clients, including R4. R6 said that Jackson yells at people when they “deserve it.” R9 recalled a dispute between S2 and Jackson, but could not provide details. R10 said Jackson does yell sometimes. R10 recalled an argument between S2 and Jackson wherein Jackson was yelling.

The department has determined the following as it relates to the allegations that staff member yells in the presence of residents in care:

Based on interviews, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Section 80072(a)(2). An exit interview was held with Jackson. Appeal rights and a copy of this report were left with Jackson.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240229092940
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2024
Section Cited
CCR
80072(a)(2)
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"… each client shall have personal rights which include, but are not limited to, the following:

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs."
This requirement was not met as evidenced by:
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Licensee verbally agreed to carry out any future staff dicsipline in a private setting. This POC will be cleared
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Based on interviews, Crisina Jackson yelled in front of residents, thereby creating uncomfortable accommodations, which poses an immediate health, safety, and/or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5