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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 12/19/2024
Date Signed: 12/19/2024 04:29:12 PM

Document Has Been Signed on 12/19/2024 04:29 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: DATE:
12/19/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:James Jordan and Nataliya ReganTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 12/19/2024, at 2:30pm, Licensing Program Analyst (LPA), Arvin Villanueva arrived unannounced to conduct a post-licensing evaluation. A pre-licensing visit was conducted on 9/10/24 for Change of Ownership (CHOW). LPA met with James Jordan and Nataliya Regan and explained the purpose of the visit.

LPA and Nataliya Regan inspected the physical plant of the facility to ensure compliance of Title 22 regulation. 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.

During this visit, LPA observed the Activity Director taking some residents to the store. Also during physical inspection, LPA observed staff going in resident rooms providing water. Some residents were observed to be playing cards in the activity area. Temperature in the hallways were observed at 70 degrees F.

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. LPA observed deck to be newly renovated.

LPA inspected 4 resident units. Each unit is fire cleared for non-ambulatory residents. The inspected resident units were observed to be furnished with adequate storage for resident belongings. Each resident unit is equiped with a 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. Water temperature: Water temperature in 4 selected bathroom (in a resident units) were measured between 116 and 118 degrees F. In 4 of 4 resident units were observed to have a smoke detector and carbon monoxide detectors. Additionally, facility is equipped with sprinkler system.

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SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
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 2
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: 12/19/2024
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Poisonous substances, sharp objects and other dangerous items were observed to be properly stored, locked, and inaccessible to residents in care. .

Facility employs an activity director. LPA observed activity calendar available for residents. 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.

Kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils were observed to be locked and inaccessible to residents. Food supply was adequate and stored in kitchen refrigerator, freezer and 2 walk-in pantries 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.



Due to insufficient time, this post licensing visit will require a continuation. The Department will return at a later date to continue the inspection.

Exit interview was conducted and a copy of this report was provided.

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

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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