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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850154
Report Date: 06/20/2022
Date Signed: 06/20/2022 11:41:45 AM

Document Has Been Signed on 06/20/2022 11:41 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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: 8DATE:
06/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Nicole Lomeli, Administrator TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 10:05 a.m., the LPA met with Administrator, Nicole Lomeli.

The reason for today's inspection is to follow up on a self-reported incident report received on 06/17/2022. The report pertains to Staff #1 (S1) regarding an alleged personal relationship with Client #1 (C1). At 10:09 a.m., the LPA conducted an interview with the Administrator. At 11:15 a.m., the LPA also reviewed records and obtained copies of pertinent documents.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is needed. Exit interview conducted and report reviewed with the Administrator. A copy of the report will be emailed.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2022
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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