<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 01/17/2025
Date Signed: 01/17/2025 03:32:23 PM

Document Has Been Signed on 01/17/2025 03:32 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: 52DATE:
01/17/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Cheryl BoehmeTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/17/25, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - visit at this facility to continue with the post-licensing Inspection visit initiated on 12/19/24. LPA met with aCheryl Boehme and stated the purpose of the visit.

This LPA continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is fire cleared for 70 residents who are non-ambulatory, 4 of which may be residents who are bedridden. Facility is approved to retain/accept 15 residents who are receiving hospice care.

LPA reviewed 5 resident files (R1 - R5). Reviews include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. No issues were noted at this time.

LPA reviewed 3 staff files (S1 - S3) which include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training.

Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan in place.

Based on today's visit, no deficiencies are being cited.

Exit interview was conducted with Cheryl Boehme and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 1