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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604589
Report Date: 11/14/2022
Date Signed: 11/14/2022 09:58:07 AM

Document Has Been Signed on 11/14/2022 09:58 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JACKSON HOUSE, THEFACILITY NUMBER:
374604589
ADMINISTRATOR:JACKSON, MAURICE A.FACILITY TYPE:
735
ADDRESS:407 OMEARA STTELEPHONE:
(619) 439-6979
CITY:SAN DIEGOSTATE: CAZIP CODE:
92114
CAPACITY: 4CENSUS: 2DATE:
11/14/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Maurice JacksonTIME COMPLETED:
10:03 AM
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Licensing Program Analyst (LPA) Ramon Serrano made an unannounced visit to the facility to conduct a post-licensing inspection. LPA was met by Licensee Maurice Jackson, was granted entry into the facility and discussed the purpose of the visit.

A tour of the facility was conducted inside and out. LPA, accompanied by Maurice Jackson conducted a general overall inspection, which included, but was not limited to the following: Facility physical plant, food service, care and supervision, medication, record review and facility administration. Administrator Certificate for Maurice Jackson expires on February 26, 2023.

During today's inspection, LPA observed the following: All indoor and outdoor passageways were free from obstructions. No pools or bodies of water were observed. Per Maurice Jackson , there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be inaccessible to clients in care. LPA toured each room in the facility. Rooms designated as client bedrooms had the required furnishings and sufficient lighting available for clients. Licensee provided each client with clean linen in good repair and sufficient hygiene products for personal use. The hot water temperature measured at 113 degrees F. The facility had multiple functioning carbon monoxide detectors and multiple smoke detectors. There was an operable fire extinguisher present in the facility, last serviced on September 2022. The facility was stocked with a two (2) day supply of perishable and seven (7) day supply of nonperishable food items. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. Client and staff records were reviewed for required documentation.

Based on today's visit, no deficiencies were observed at this time in the areas evaluated above. A copy of this report, along with Licensee/Appeal Rights, was provided to Maurice Jackson at the conclusion of the visit, and signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Ramon Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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