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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850154
Report Date: 12/02/2022
Date Signed: 12/02/2022 04:14:53 PM

Document Has Been Signed on 12/02/2022 04:14 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:NICOLE LOMELIFACILITY TYPE:
772
ADDRESS:811 TELEGRAPH ROADTELEPHONE:
(619) 507-6385
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 16CENSUS: 9DATE:
12/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Nicole LomeliTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 1:00 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Nicole Lomeli and explained the reason for the visit. This is a social rehabilitation facility which houses clients typically for a maximum of 30 days.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers, carbon monoxide, smoke alarms and fire suppression system were last tested 11/11/2022 by Intelligent Fire Systems & Solutions, Inc.

KITCHEN: The kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed eight double-occupancy rooms which were appropriately furnished, clean and had sufficient lighting. RESTROOMS: There is one restroom for women and one for men. Each restroom is equipped with two toilet stalls and two shower stalls. Restrooms were clean and sanitary and in operating condition. COMMON SPACES: The lobby, activity room/dining room and lounge area were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio area was equipped with furniture for residents' use.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Exit interview conducted. A copy of the report was emailed to the Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2022
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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