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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850154
Report Date: 02/10/2025
Date Signed: 02/10/2025 05:21:17 PM

Document Has Been Signed on 02/10/2025 05:21 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: 16DATE:
02/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Nicole LomeliTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 12/06/2024. The LPA was greeted by Administrator Nicole Lomeli and informed them of the reason for the visit.

Today the LPA conducted a medication audit and finished the record review initiated on 12/06/2024.

Record Review: The LPA reviewed five (5) staff files. All documents reviewed appeared complete and current.

Medications: A medication review was initiated and the following was observed. The medications were stored in Med carts, which are locked and inaccessible to the clients inside the medication room. During Client' #1 (C#1's) audit, the LPA observed the prescription number for three (3) medications not documented, and the quantity number for two (2) medications not properly documented as they did do not match the facilities records.


Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2025
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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Document Has Been Signed on 02/10/2025 05:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/10/2025 at 05:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JACKSON HOUSE SANTA PAULA
FACILITY NUMBER: 565850154

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
81075(k)(7)
Health-Related Services
(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 which is retained for at least one year and includes the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and record review, the licensee did not comply with the section cited above in four medications that did not have their prescription number recorded or quantity number was not recorded properly which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Licensee agrees to complete a medication audit to ensure all medications are properly documented. Complete audit by 02/21/2025 and informed CCL when audit is complete not later than the POC due date. Licensee also agrees to complete medication staff training around documenting incoming medications and to ensure consistency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/10/2025


LIC809 (FAS) - (06/04)
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