565850154-3-13-2026-29-AS-KLOZ-DUJ6HV-20260528205005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850154
Report Date: 03/13/2026
Date Signed: 03/13/2026 03:34:21 PM

Unsubstantiated

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
08/07/2025 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20250807110633

FACILITY NAME:	JACKSON HOUSE SANTA PAULA		FACILITY NUMBER:	565850154
ADMINISTRATOR:	NICOLE LOMELI		FACILITY TYPE:	772
ADDRESS:	811 TELEGRAPH ROAD		TELEPHONE:	(619) 507-6385
CITY:	SANTA PAULA	STATE: CA	ZIP CODE:	93060
CAPACITY:	16	CENSUS: 16	DATE:	03/13/2026
		UNANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Nicole Lomeli		TIME COMPLETED:	03:36 PM

ALLEGATION(S):

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Staff threaten residents with physical harm
Staff are not maintaining residents’ medical information confidential

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Esther Cortez conducted an unannounced subsequent complaint visit for the above allegations. Upon arrival, LPA met with Program Director Nicole Lomeli and explained the reason for the visit. Entrance interview conducted.

On 08/12,2025, between 09:40 a.m. and 3:30 p.m., the LPA interviewed the Program Director, five (5) staff, two (2) clients, conducted a medication audit and obtained copies of resident records and other pertinent documents relevant to the investigation. On 12/16/2025, between 10:00 a.m. and 3:30 p.m., the LPA toured the facility inside and out, interviewed the Program Director, four (4) staff, six (6) clients, and obtained copies of resident and staff rosters. On 01/14/2026, the LPA conducted interviews with one (1) staff and the Program Director, conducted a file review and obtained perinent copies relevant to the investigation.

Report will continue on LIC9099-C, 2nd page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026

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 4

Control Number 29-AS-20250807110633

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: 03/13/2026

NARRATIVE

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During today's visit, between 9:36 a.m. and 3:30 p.m., the LPA conducted a telephone interview with one (1) staff, conducted a file review, and collected pertinent documents relevant to the investigation.

Regarding the allegation, “Staff threaten residents with physical harm”; it is the concern of the Reporting Party (RP) that Staff 1 (S1) threaten Client 1 (C1) by allegedly telling them “I’ll break your neck if you leave.” All nine (9) out of nine (9) staff interviewed, including S1, revealed that they have never threatened, heard or witnessed any staff threatening any of the clients with physical harm and if they did, they would report it. Interview conducted with S1 revealed that they had been previously asked by a client if they had said that they would break C1’s neck, that comment was going around, and they said to the client “no, I didn’t say that you heard wrong”. S1 further revealed that they recall C1, and they had a good rapport with C1 and do not know why anyone would say they said that. On 08/12/2025, the LPA attempted to contact C1, as they are no longer at the facility, however the LPA was unable to get in contact with C1. Eight (8) out of eight (8) Interviews conducted with clients revealed that they have never witnessed any staff threaten any client, have never been threatened by staff and feel safe at the facility. Although the allegation may have happened or is valid, based on interviews with nine (9) staff and eight (8) clients the department does not have sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation, ‘Staff threaten residents with physical harm” is UNSUBSTANTIATED at this time.

On the allegation, “Staff are not maintaining residents’ medical information confidential’ it is the concern of the Reporting Party (RP) that staff talk about client’s information, including medical information, in front of other clients. Nine (9) out of nine (9) staff interviewed denied sharing client information with other clients. Staff revealed that for them to provide any information about a client the client needs to have a signed Release of Information (ROI) form on file, and that form will indicate who they are able to share client information with. Staff cannot even confirm or deny if a client is at the facility without first making sure the client has a ROI and the person asking is listed on the ROI form. Staff further reveal that if they are talking about clients information, they ensure they do it in a private setting where other clients cannot hear. Eight (8) out of eight (8) clients interviewed revealed that they do not have any concerns about staff sharing their medical information, they signed a ROI so the staff know who they are able to share their information with, and have not heard staff talking about other client’s medical information in front of them.

Report will continue on LIC9099-C, 3rd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20250807110633

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: 03/13/2026

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Although the allegation may have happened or is valid, based on the information gathered the department does not have sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation, ‘Staff are not maintaining residents’ medical information confidential’” is UNSUBSTANTIATED at this time. Exit interview was conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4