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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850154
Report Date: 11/24/2021
Date Signed: 11/24/2021 03:32:47 PM

Document Has Been Signed on 11/24/2021 03:32 PM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JACKSON HOUSE SANTA PAULAFACILITY NUMBER:
565850154
ADMINISTRATOR:ZIEMER, PATRICKFACILITY TYPE:
772
ADDRESS:811 TELEGRAPH ROADTELEPHONE:
(619) 507-6385
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 16CENSUS: 0DATE:
11/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Patrick ZeimerTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Angel Ascencio and Kelly Dulek conducted a Pre-Licensing Inspection with Applicant Representative Patrick Zeimer and Program Director Nicole Lomeli. An Application to operate a Social Rehabilitation Facility (SRF) was received by Community Care Licensing (CCL) on 11/15/2021. A Fire Clearance was approved for a maximum capacity of sixteen(16) ambulatory residents on 10/15/2021.

The proposed physical plant is a single story facility located in a residential neighborhood of Santa Paula, CA. A tour of the physical plant was conducted and the following observed:

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient non-perishable food to accommodate a maximum capacity of 16 Clients for (seven) 7 days. There was sufficient dining and cook ware to accommodate a maximum capacity of 16 Clients. Cleaning supplies were stored in locked under-sink cabinets and locked closet. Knives and other sharps will be stored in a locked cabinet. Water temperature was measured and was within range of 105 degree F to 120 degrees F at the time of visit. There were no visible immediate hazards observed.

BEDROOMS: There are eight (8) Bedrooms, all of which are designated for resident use. All bedrooms are furnished for double occupancy. All bedrooms were equipped and supplied with appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

BATHROOMS: There are three (3) Bathrooms, two (2) are for resident use and one (1) is for staff. The resident bathrooms are full bathrooms with overhead shower head, non-skid tile and shower bench. All bathrooms were supplied with appropriate paper and hygiene products. COVID-19 signs are required inside all bathrooms and were observed during the visit. Water temperatures were measured in all bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit. Continued on LIC-809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE: DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/24/2021
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JACKSON HOUSE SANTA PAULA
FACILITY NUMBER: 565850154
VISIT DATE: 11/24/2021
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COMMON AREAS: These include the Common Area Room and Dining Room. The common areas were furnished to accommodate a maximum capacity of sixteen (16) residents. The Fire safety inspection clearance was approved on 10/15/2021. Fire extinguishers and carbon monoxide detectors were observed throughout the facility. There were no immediate hazards observed. A COVID-19 Screening & Hand Sanitizing Station was observed at the entrance to the facility. COVID-19 signs were observed throughout the facility common areas.

CONSULT/COUNSELOR, MEDICATION ROOM & OFFICE AREAS: There is a Consult Room, a Medication Room and a Counselor Room at the premise. Medications are stored in a locked cabinet and refrigerator in the Medication Room. The 1st Aid Kit is stored in the Medication Room and locked storage area.

LAUNDRY: Laundry room was observed to be locked and contained laundry supplies in a locked cabinet.

SURROUNDING GROUNDS: The back patio is fenced and includes a patio with furniture appropriate for outdoor use and shade for the residents. There were no visible immediate hazards or deficiencies.

COMPONENT III ORIENTATION: A Component III Orientation was completed with the Licensee Representative and Program Director on 11/24/2021 during pre-licensing visit for Jackson Home Santa Paula # 565850154.

COVID-19 MITIGATION PLAN REPORT: During today’s visit, LPAs reviewed the facility’s Plan for Epidemic Outbreak specific to COVID-19 Mitigation Plan Report.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the Licensing Report was provided via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2021
LIC809 (FAS) - (06/04)
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