<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603946
Report Date: 09/30/2022
Date Signed: 09/30/2022 12:08:22 PM

Document Has Been Signed on 09/30/2022 12:08 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JACKSON HOUSEFACILITY NUMBER:
374603946
ADMINISTRATOR:LINDSAY TAYLORFACILITY TYPE:
772
ADDRESS:5332 JACKSON DRIVETELEPHONE:
(619) 303-0933
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 15CENSUS: 11DATE:
09/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Executive Clinical Director, Lauren Tozzi TIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced Case Management visit. LPA was allowed entry by receptionist, Eva Lopez, and met with Executive Clinical Director, Lauren Tozzi. LPA identified herself and discussed the purpose of the visit.

Today's visit was in response to self-reported death of Client #1 (C1). [See LIC 811 Confidential Names List for a description of C1]. C1 passed on 09/25/2022 away from the facility. LPA conducted interviews with staff, collected records, and conducted a tour of the facility.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Executive Clinical Director, Lauren Tozzi, to whom a copy of this report and an appeal rights (LIC9058 03/22) were provided via hardcopy of the conclusion of the visit.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Kayla Hilario
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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 1