565850154-3-26-2026-29-AS-KLOZ-DUJ6HU-20260528205005

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850154
Report Date: 03/26/2026
Date Signed: 03/26/2026 01:22:17 PM

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
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: 14	DATE:	03/26/2026
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Nancy Garcia Office Manager		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff are not ensuring residents are provided their medication as prescribed
Staff are not properly documenting the MAR

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 Office Manager Nancy Garcia and explained the reason for the visit. Progam Director Nicole Lomeli is not able to be present during today's 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.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

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 5

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: 03/26/2026

NARRATIVE

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On 03/13/26, 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. During today's visit the LPA conducted one (1) phone interview with former staff, attempted to conduct phone interviews with Client 4 (C4), and one (1) witness, conducted a file review and collected pertinent documents relevant to the investigation.

Regarding the allegations, “Staff are not ensuring residents are provided their medication as prescribed and Staff are not properly documenting the MAR,” it is the concern of the Reporting Party (RP) that staff failed to ensure residents received medications as prescribed and failed to properly document the Medication Administration Record (MAR). Specifically, the Reporting Party (RP) expressed concerns regarding medication errors during client crises, improper documentation leading to double-dosing, and the administration of medications without valid prescriptions.

The RP reported that on 05/09, (no year was provided) a client received 1.0 mL of Testosterone instead of the ordered 0.2 mL. Program Director Nicole Lomeli and a review of the Kipu EMR system could not identify a client matching the specific name provided by the RP. However, a client (C4) with a similar nickname was identified as receiving Testosterone. During a phone interview, the Director of Nursing (DON) revealed they were unaware of any errors involving C4. During a phone interview, Staff 2 (S2) recalled C4 requesting a dose reduction from the prescribed 200mg, but S2 denied deviating from the doctor's order and stated the client was advised S2 could consult their physician. C4 has since discharged; the LPA attempted to contact C4 via telephone but was unsuccessful.

The DON confirmed that on 11/18/23, Client 2 (C2) received a double dose of Adderall (60mg total). The error occurred because the NOC shift nurse administered the morning dose but failed to record it in the narcotic binder. Consequently, a Mental Health Technician (MHT) administered a second 30mg dose later that morning. The DON stated C2 was monitored, remained asymptomatic, and the physician was notified.

The DON also confirmed that on 03/16/25, Client 3 (C3) was administered Suboxone 12-4mg without a current order. C3 was prescribed Subutex, but staff substituted Suboxone from existing stock because the client had previously been on that medication. Report will continue on LIC9099-C, third page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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: 03/26/2026

NARRATIVE

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The DON acknowledged that while Medication Variances were completed for the Adderall and Suboxone incidents, these errors were not reported to Community Care Licensing (CCL), as the facility does not typically report errors that do not require medical intervention.

The LPA received and reviewed Medication Variance Records for both incidents which confirmed that on 11/18/23, Client 2 (C2) received a double dose of Adderall (60mg total) and that on 03/16/25, Client 3 (C3) was administered Suboxone 12-4mg without a current order. Interviews and file reviews confirmed that staff failed to document controlled substances properly, resulting in a double dose for one client, and administered a medication to another client without a valid physician's order. Based on the information gathered there is enough evidence to support the allegations. Therefore, the allegations are Substantiated.

Pursuant to Title 22, California Code of Regulations, a deficiency is cited (refer to LIC 9099-D). An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/03/2026 Section Cited CCR 81075(b)	1 2 3 4 5 6 7	Health-Related Services 81075 (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: Based on file review and interviews, the licensee did not comply with the section	1 2 3 4 5 6 7	Office Manager agrees that all nursing and MHT staff will complete a mandotary medication Rights (Right Patient, Right Drug, Right Dose, Right Route, Right Time) triaining and submit proof.
	8 9 10 11 12 13 14	cited above when C2 received a double dose of Adderall (60mg) when only 30mg was prescribed and C3 recieved medication with no current order at the time, which poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14
Type B 04/03/2026 Section Cited CCR 81075(k)(7)	1 2 3 4 5 6 7	(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications ... This requirement is not met as evidenced by: Based on file review and interviews the	1 2 3 4 5 6 7	Office Manager agrees that all nursing and MHT staff will complete a mandotary medication training regarding documentation and submit proof to LPA.
	8 9 10 11 12 13 14	licensee did not comply with the section cited above when the NOC shift nurse failed to log the administration of a controlled substance (Adderall) wich directly led to the subsequenr medication error of C2, which posed a potential health and safety risk to persons in care	8 9 10 11 12 13 14

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2026

LIC9099 (FAS) - (06/04)

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