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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700219
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:50:22 AM

Document Has Been Signed on 12/19/2023 11:50 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JACKTONE ROAD CARE HOMEFACILITY NUMBER:
392700219
ADMINISTRATOR:QURESHI, MUHAMMADFACILITY TYPE:
735
ADDRESS:16046 JACKTONE RDTELEPHONE:
(209) 224-1948
CITY:LODISTATE: CAZIP CODE:
95240
CAPACITY: 6CENSUS: 3DATE:
12/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:umer QureshiTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to conduct a case management visit for an indent report recieved by the department on 12/18/23. Incident occurred on 12/16/2023. LPA was greeted by staff and explained the reason for the visit.

LPA reviewed R1'S file and took copies of the Physician's Report (602),Pre admissions assessment, R1's medication administration record (MAR), and the needs and service plan, LIC 500 and staff schedule.

911 was called for R1 after staff noticed they were weak and all additional information came from R1'S family.

This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties.



An exit interview was conducted and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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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