374603946-1-21-2025-08-AS-SJAB-DFXTRP-20250421145752

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603946
Report Date: 01/21/2025
Date Signed: 01/21/2025 11:57:44 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2023 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20230209080726

FACILITY NAME:	JACKSON HOUSE		FACILITY NUMBER:	374603946
ADMINISTRATOR:	LINDSAY TAYLOR		FACILITY TYPE:	772
ADDRESS:	5332 JACKSON DRIVE		TELEPHONE:	(619) 303-0933
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	15	CENSUS: 11	DATE:	01/21/2025
		UNANNOUNCED	TIME BEGAN:	11:26 AM
MET WITH:	Eva Lopez, Office Manager		TIME COMPLETED:	12:05 PM

ALLEGATION(S):

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Lack of supervision resulting in client's death
Licensee did not seek medical attention for client

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)Tiffany Holmes conducted an unannounced complaint visit to the facility to deliver findings on the above-mentioned allegation. LPA gained access to the facility, identified herself, and met with Eva Lopez, Office Manager to discuss the purpose of the visit.

A death report was received by the San Diego Adult and Senior Care Program reporting Jackson House Client 1 (C1) escaped a vehicle during his transport by Jackson House staff, ran into oncoming traffic on the freeway, returned to the vehicle and sped away. R1 drove to a freeway overpass and jumped off, causing their death.

Interviews revealed on 09/25/2022 the client was being transported via Jackson House staff and vehicle due to a non-emergency voluntary trip agreed upon by C1 to the hospital. C1 was assessed and evaluated by medical staff and psychiatrist on site at Jackson House the day of, and days prior to the transport. C1 did not exhibit suicidal ideation and did not present or verbalize any plan to commit suicide

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

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 08-AS-20230209080726

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACKSON HOUSE	FACILITY NUMBER: 374603946
	VISIT DATE: 01/21/2025

NARRATIVE

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C1 expressed passive ideation and was referred to the hospital on a voluntary basis for increasing depression and to have their medications reassessed. The case report from the California Highway Patrol (CHP) was obtained and interviews revealed CHP conducted interviews with the Jackson House administrator, who conducted the transport, with the Jackson House Executive Clinical Director, and several motorist eyewitnesses to the event which included witnesses that observed C1 jumped from the bridge and fall to their death. The case report from the California Highway Patrol reported that the Medical Examiner's office stated this caused C1s death. The report documents the absence of foul play and ruled the incident a suicide.

It was alleged that the licensee did not seek medical attention for client. Interviews revealed that their intake date was 09/12/2022 seen by the Nurse Practitioner (NP). Client was seen 09/15/2022, 09/20/22, 09/24/2022 by the NP again. C1 was seen several times. C1 was referred to the hospital on a voluntary basis for increasing depression and to have their medications reassessed on 09/25/2022 C1 continued to refuse medications. On 09/25/2022 C1 was being transported by Jackson House staff to the hospital for a voluntary treatment seeking a higher level of care due to worsening symptoms of anxiety and depression. Interviews revealed that prior to the transport, C1 was evaluated by the facility Director of Nursing Practice (DNP), and their psychiatrist on 09/24/2022.

The investigation did not produce supporting evidence or supporting witness statements to substantiate an allegation of questionable death. The allegations of questionable death and licensee did not seek medical attention for client are unsubstantiated.

An exit interview was conducted Eva Lopez, Office Manager to whom a copy of this report, LIC 811 (Confidential Names List), and the Applicant/Licensee Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Tiffany Holmes
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025

LIC9099 (FAS) - (06/04)

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