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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603946
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:59:53 PM

Document Has Been Signed on 05/15/2024 03:59 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 DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JACKSON HOUSEFACILITY NUMBER:
374603946
ADMINISTRATOR/
DIRECTOR:		LINDSAY TAYLORFACILITY TYPE:
772
ADDRESS:5332 JACKSON DRIVETELEPHONE:
(619) 303-0933
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 15CENSUS: 12DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:LVN Islamudin "Izzy" ZainulabudinTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Manager (LPM) Simon Jacob and Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Case Management – Incident visit. LPA was allowed entry into the facility by Staff Kayla Romero and met with LVN Islamdin Zainulabudin.


Today's visit was in response to a Special Incident Report (SIR), in which licensee self submitted to the CCLD San Diego Regional Office on 03/15/2024 in relation to a medication error by a designated pharmacy. The discrepancy led to a medication error by the facility.

During today’s visit, LPM and LPA toured the facility, conducted interview and collected relevant records. No deficiencies were observed or cited during today's visit. An exit interview was conducted with LVN Islamudin Zinulabuidn to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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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