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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209307
Report Date: 07/06/2023
Date Signed: 07/06/2023 11:57:40 AM

Document Has Been Signed on 07/06/2023 11:57 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JACKSON HOUSE TULAREFACILITY NUMBER:
547209307
ADMINISTRATOR:ZIEMER, PATRICKFACILITY TYPE:
772
ADDRESS:1168 LELAND AVETELEPHONE:
(619) 507-6385
CITY:TULARESTATE: CAZIP CODE:
93274
CAPACITY: 16CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Licensee, Patrick Ziemer Licensee
Administrator, Martha Renteria 		TIME COMPLETED:
12:30 PM
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On 07/06/23, Licensing Program Analyst (LPA) L. Salazar arrived at the facility announced to conduct the pre-licensing inspection. LPA was greeted by licensee, stated the purpose of the visit and was allowed entry into the facility.

LPA conducted a tour of the facility. LPA observed indoor and outdoor passageways, to be free from obstruction. LPA observed 8 resident bedrooms to have the required furnishings. Facility had 4 bathrooms and 3 shower rooms. Residents bedrooms were observed to be free from odor. A tank less hot water heater was observed temperature at a temperature of 120 degrees F. Trash can with lids and hand washing postings were observed in bathrooms. Infection Control Policy was observed and submitted to CCL. An Internet device was observed to be available for residents in care. Carbon monoxide and smoke detectors were observed to be operational. Fire Extinguisher was observed with a service date of 06/13/23. First aid kit was observed. Medications were observed to be in a locked medication cart located in a locked nursing station. Cleaning supplies were observed to be in a locked closet.

A sample of facility, resident and staff files were observed. Facility sketch was observed to have a clearly identified assembly point. Facility’s keys to entrance/exit doors and vehicles are planned to be available to staff on all shifts. Two emergency shelter locations are identified in LIC 610D, with one of the locations being outside of the immediate area. Emergency medical services contact information is observed to be available for staff. An emergency disaster binder was observed and readily available for Emergency Services.

(Continued 809-C)

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: JACKSON HOUSE TULARE
FACILITY NUMBER: 547209307
VISIT DATE: 07/06/2023
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(Continued from 809-C)

An exit interview was conducted, and a copy of this report was discussed and provided to Licensee. Component III was conducted during today's pre-licensing visit.

LPA has found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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