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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850154
Report Date: 12/06/2024
Date Signed: 12/06/2024 03:16:09 PM

Document Has Been Signed on 12/06/2024 03:16 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JACKSON HOUSE SANTA PAULAFACILITY NUMBER:
565850154
ADMINISTRATOR/
DIRECTOR:
NICOLE LOMELIFACILITY TYPE:
772
ADDRESS:811 TELEGRAPH ROADTELEPHONE:
(619) 507-6385
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 16CENSUS: 12DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Nicole LomeliTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:35 a.m. The LPA met with staff and explained the reason for the visit. Administrator Nicole Lomeli arrive shortly after. This is a social rehabilitation facility which houses clients typically for a maximum of 30 days.

The LPA and Administrator 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 carbon monoxide, smoke alarms were tested and operable during today's visit. The fire extinguishers were fully charges and last inspected on 04/19/2024.

KITCHEN: The kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food. The kitchen remains locked if staff are not inside and knives are kept in a locked drawer in the kitchen. Cleaning supplies are kept in a locked maintenance closet. The hot water measured 113.9*F.

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. The smoking area is also equipped with furniture for residents' use.

INTERVIEWS: The LPA interviewed three residents during today's visit. No immediate concerns were voiced. Report will continue on LIC809-C, 2nd page.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JACKSON HOUSE SANTA PAULA
FACILITY NUMBER: 565850154
VISIT DATE: 12/06/2024
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INFECTION CONTROL: 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 or other infectious diseases.

Record Review: A review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and last fire/disaster drill (conducted on 10/17/24). The LPA obtained Client Roster, Staff Roster, and Staff schedule. The LPA reviewed five (5) of twelve (12) Client Files. All client documents reviewed appeared complete and current.

Due to time constraint the LPA will return at a later date to complete the annual.

No Deficiencies cited. Exit interview conducted. Report provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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