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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850154
Report Date: 05/21/2024
Date Signed: 05/22/2024 09:06:26 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/15/2024 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20240515115251
FACILITY NAME:JACKSON HOUSE SANTA PAULAFACILITY NUMBER:
565850154
ADMINISTRATOR:NICOLE LOMELIFACILITY TYPE:
772
ADDRESS:811 TELEGRAPH ROADTELEPHONE:
(619) 507-6385
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY:16CENSUS: 16DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Nicole LomeliTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff had inappropriate relationships with clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigatin visit regarding the above noted allegation. LPA met with administrator Nicole Lomeli and explained the reason for the visit.

LPA interviewed the administrator at 10:56 a.m. and staff at 11:20 a.m., 11:26 a.m., 11:32 a.m., 12:18 p.m., 3:02 p.m., and 3:13 p.m. at the facility. LPA interviewed staff over the phone at 2:25 p.m. and attempted staff interviews over the phone at 2:23 p.m. and 2:24 p.m. LPA reviewed records at 12:30 p.m.

During the course of the interviews, staff stated that staff 1 (S1) lacked boundaries with client 1 (C1). S1 was observed to be exceedingly friendly with C1 moreso than with other clients. S1 would have C1 come into the kitchen with them to make food; something seen by other clients and staff as a priviledge for clients. S1 was observed dancing in the kitchen with C1. S1 was also observed staying after their shift to

(continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240515115251
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JACKSON HOUSE SANTA PAULA
FACILITY NUMBER: 565850154
VISIT DATE: 05/21/2024
NARRATIVE
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(continued from 9099)

spend time with C1. S1 had been counseled by management to maintain appropriate boundaries with clients.

It was later learned after C1 was discharged from this facility, S1 maintained contact with C1 in a non-professional role.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240515115251
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JACKSON HOUSE SANTA PAULA
FACILITY NUMBER: 565850154
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2024
Section Cited
CCR
81072(a)(1)
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81072 PERSONAL RIGHTS (a) Each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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The administrator will conduct training with staff regarding professional boundaries and the expectation of reporting unusual activities of clients and/or staff to the administrator. Evidence of this training will be provided to CCL by 5/29/2024.
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Based on interviews and record review, the licensee did not comply with the above cited section, as S1 was observed multiple times not maintaining professional boundaries with C1, which poses a potenital health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3