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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:40:40 PM

Document Has Been Signed on 09/10/2024 03:40 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JACKSON HILLS ASSISTED LIVING LLCFACILITY NUMBER:
032701408
ADMINISTRATOR/
DIRECTOR:		JORDAN, JAMESFACILITY TYPE:
740
ADDRESS:223 NEW YORK RANCH ROADTELEPHONE:
(916) 212-0275
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 70CENSUS: 44DATE:
09/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:James Jordan, Nataliya Regan, and Cheryl BoehmeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 9/10/2024, at 10:00am, Licensing Program Analyst (LPA), Arvin Villanueva arrived unannounced to conduct an inspection to the above facility for purpose of a pre-licensing evaluation. This pre-licensing is for Change of Ownership (CHOW). LPA met with James Jordan, Nataliya Regan, and Cheryl Boehme, and explained the purpose of the visit.

LPA, Cheryl Boehme, and Nataliya Regan inspected the physical plant of the facility to ensure compliance of Title 22 regulation. LPA observed 8 random resident units, the activity room, dining room, kitchen, laundry, and outdoor areas. Facility has a 70-resident capacity for Assisted Living residents, 4 of which is fire cleared for bedridden residents. Facility is a one-story building located in a residential neighborhood. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. LPA did not observe bodies of water at this time.

Bedrooms Residents: LPA inspected 8 resident units. Each unit is fire cleared for non-ambulatory residents. The resident apartments/units are spacious and will easily accommodate the residents furnishings. The inspected resident units were observed to be furnished with adequate storage for resident belongings.

Bathroom: Each resident unit contain private bathroom. All bathrooms inspected have working toilets, wash basins and full baths have showers. There are grab rails next to both the toilets and the showers as well as nonskid flooring.

Toxins and Chemicals: Toxins and chemicals for cleaning are properly stored, locked, and inaccessible to residents in care. .

Water temperature: Water temperature in a randomly selected bathroom (in a resident units) were measured at 112 and 119 degrees F.

Activities: Facility employs an activity director. LPA observed activity calendar for residents' use. LPA observed an activity area in the facility. Outside activity area is properly enclosed. Doors leading to the outside have auditory devices to monitor exits.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JACKSON HILLS ASSISTED LIVING LLC
FACILITY NUMBER: 032701408
VISIT DATE: 09/10/2024
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Food Service and Kitchen: Kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils are in locked and inaccessible to residents. Food supply was adequate and stored in kitchen refrigerator and walk-in pantry and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Stove burners and oven were observed to be in good repair. Temperatures in refrigerator and freezer were observed to be within regulatory standard. Menu was observed and available to residents in care.

Smoke Detectors/Carbon Monoxide: Each inspected resident units were observed to have a smoke detector and carbon monoxide detectors. Additionally, facility is equipped with sprinkler system. Smoke detectors are hardwired and interconnected, and they are fully operational. Facility conducts quarterly disaster emergency drills.

Medications and First-Aid Kit: Resident medications were observed to be stored in the medication room and observed to be locked and inaccessible to residents in care. First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients.

Facility, Residents & Staff Files: Applicant will not be handling cash resources of residents. Records of staff and residents are stored in a locked room and accessible to staff. LPA reviewed 5 resident files and 5 staff files. LPA provided licensee the form LIC311F (Records to be Maintain at the Facility - RCFE) to ensure facility maintains required records at all times.

Component III: Conducted at the Pre-Licensing visit, on 9/10/2024 at Jackson Hills Assisted Living, information provided about how to operate the facility within substantial compliance.

Pre licensing is complete and this facility has no deficiencies.

An exit interview was conducted with James Jordan, Nataliya Regan, and Cheryl Boehme. A copy of this report was provided.

Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant have questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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