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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880870
Report Date: 09/17/2021
Date Signed: 09/17/2021 11:35:45 AM

Document Has Been Signed on 09/17/2021 11:35 AM - 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACKSON HOMEFACILITY NUMBER:
361880870
ADMINISTRATOR:CORONADO, VALERIEFACILITY TYPE:
735
ADDRESS:4873 JACKSON COURTTELEPHONE:
(909) 590-2038
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 4DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:36 AM
MET WITH:Caregiver Ester RomeroTIME COMPLETED:
11:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control.

LPA Gardner met with Caregiver Esther Romero, and Caregiver Rosa Argueta. Present in the home during time of visit were 4 clients. There are currently no cases of COVID-19 within the facility.

During today's visit, LPA Gardner toured the facility and made observations pertaining to the facility's infection control measures. LPA Gardner observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control.

During the inspection LPA Gardner noticed an unlocked cabinet underneath the kitchen sink that contained resident medication. While reviewing the Guardian Employee Roster, LPA Gardner found that Caregiver Rosa Argueta was not on the roster for clearance. After interviewing Ms. Argueta, LPA Gardner found that according to Ms. Argueta, she has worked at this facility every Friday since June, 2020. During the investigation, Ms. Argueta was found to be associated to Sumsong Home (LIC#361880876).

During the visit, Administrator Valerie Coronado arrived to the facility.

LPA Gardner discussed infection control practices and procedures with Ms. Coronado. An exit interview was conducted and a copy of this report, as well as the LIC809(d), LIC421BG, and the Appeal Rights was reviewed with and provided to Ms. Coronado.
SUPERVISORS NAME: Reyna Lacey
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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Document Has Been Signed on 09/17/2021 11:35 AM - It Cannot Be Edited


Created By: Jesse Gardner On 09/17/2021 at 10:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JACKSON HOME
FACILITY NUMBER: 361880870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited

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Health Related Services - 80075(n)(1)

Medications are kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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This requirement was not being met as evidenced by: LPA Gardner observed unlocked cabinet accessible to residents in care. This poses a potential health and safety risk to residents in care.
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Type A
09/17/2021
Section Cited

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Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) or
This requirement was not met as evidenced by:
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Licensee did not ensure S1, obtained a criminal record transfer prior to beginning working at facility. Based on record review and interview, S1 has been working at the facility approximately since 06/2020. This poses an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME:Reyna Lacey
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021


LIC809 (FAS) - (06/04)
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