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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880870
Report Date: 10/29/2024
Date Signed: 10/29/2024 04:40:16 PM

Document Has Been Signed on 10/29/2024 04:40 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JACKSON HOMEFACILITY NUMBER:
361880870
ADMINISTRATOR/
DIRECTOR:		CORONADO, VALERIEFACILITY TYPE:
735
ADDRESS:4873 JACKSON COURTTELEPHONE:
(909) 590-2038
CITY:CHINOSTATE: CAZIP CODE:
91710
CAPACITY: 4CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:35 PM
MET WITH:Valerie Coronado, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 10/29/2024 at 03:35 PM, Licensing Program Analysts (LPAs) Eldin Serrano and Mary Rico conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection. LPAs were greeted by Administrator Valerie Coronado and gained access at the home. LPAs explained the purpose of the visit to Administrator Valerie Coronado.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). The facility are licensed for 4 ambulatory. LPAs completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPAs observed four (4) client during the visit. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPAs inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 110 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. .

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPAs observed night lights at the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: JACKSON HOME
FACILITY NUMBER: 361880870
VISIT DATE: 10/29/2024
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Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPAs observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPAs reviewed three (3) client files for admission agreements, medical assessments/physician reports, and Individual Program Plan (IPP). LPAs observed files reviewed were complete. LPAs also reviewed two (2) staffs and administrator's file for First Aid/CPR certification, emergency intervention certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPAs audited three (3) clients’ medications and no issues were observed. LPAs audited three (3) client's Personal and Incidental (P&I) and no issues observed.

No deficiency were cited during this visit. An exit interview was conducted where this report LIC809, was discussed, and copies were provided to Administrator Valerie Coronado.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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