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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 032701408
Report Date: 08/28/2025
Date Signed: 08/28/2025 07:58:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/21/2025 and conducted by Evaluator Noel Wolf Petersen
COMPLAINT CONTROL NUMBER: 27-AS-20250821112407
FACILITY NAME:JACKSON HILLS ASSISTED LIVING LLCFACILITY NUMBER:
032701408
ADMINISTRATOR:JORDAN, JAMESFACILITY TYPE:
740
ADDRESS:223 NEW YORK RANCH ROADTELEPHONE:
(916) 212-0275
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:70CENSUS: 61DATE:
08/28/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Cheryl BoehmeTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Facility staff are not providing residents medication as prescribed.
Facility staff do not provide adequate food service to residents in care.
INVESTIGATION FINDINGS:
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on 8/28/25, at 10:00 Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced met Cheryl Boehme and Natalyia Regan to explain purpose of the visit to open complaint investigation.

Observation of services(2pm Medication pass and lunch/dinner meal service). MAR confirms that in at least one instance a medication(heart medication) was not delivered to a resident in time with thier perscribed order for a period of 3 days. Administration does not have a record of increased staff monitoring the residents who were between medications. Records are not detailed enough to account refusals and PRNs, status of med delivery(availible at pharmacy/in transit/ect). LPA is providing guidance that to meet the nessisary reporting requirements and to reach the level of detail in record keeping to be compliant with titlle 22 state regulation, a single staff is not adquate to meet the needs of 61 people let alone 70 in a safe and comfortable manner.

Continued on C Page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20250821112407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/28/2025
NARRATIVE
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 Meal services are supplied to 61 residents, from a staff of 3-5, one to two chefs and 2-4 handlers. The kitchen is in some state of renovation where potentialy inedible or toxic matierals might enter the food during preperation. LPA observed work being done durring the lunch and service, with contractors bringing matierials into the work area through the food prep area. LPA observed the dinner meal service was not provided as described on the menu(forgotten marinara sauce for a raviolli dish), which resulted in some substantial nutrient and calorie content loss. Kitchen staff recive a lot of complaints about all meal services, LPA provided guideance that there seems to be bottlenecks coming from hardware and staffing limitations ( in the dinner service specificly with 1 chef, 2 handlers) in the capacity to great deal of difficulty in providing 61 meals, request handling for alternate menu items, adjustments for perscriptive diets, ect.

Based on LPAs observations, interviews, observations, and record reviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED.

Per title 22 citations were issued, on a following D Page. Appeal rights were provided. An exit interview was conducted, and a copy of the report was read and given to the administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250821112407
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/29/2025
Section Cited
CCR
87465(c)(2)
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87465 Incidential Medical and dental Services (c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided...: (2) Once ordered by the physician the medication is given according to the physician's directions.
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The Facility will make sure medication is availible to the residents as perscribed, including having detailed records that reflect a status the medication is in if it's not in the care of the facility, including what will be done to keep the resident safe when medication is in a nondeliverable state.
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The requirement was not met as the result of:
record review of the mar showing a period of 3 days where neither of the perscribed heart medications were not availible to the resident for reasons unknown
This poses an immediate health and saftey risk to persons in care.
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a sample Copy of the new record keeping process, a detailed documentation for the refusal process, a detailed documentation for the prn process, will be given to the LPA end of buisness friday, 8/29/25.
Type A
08/29/2025
Section Cited
CCR
87555(a)
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87555 General Food service requirements (a) the total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner.
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No plan of correction needed. The Facility set up a barrier between the two work areas. The barrier shall be maintained for the period of the work being done, the facility will invest resources in its maintaince, and the maintanience in a pest free envionment during the work period.
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The requirement Was not met as evidenced by:
LPA's observation of the kitchen in a state of renovation where particles and workers could travel into the food served during meal preperation.
This poses an immedate risk to health to persons in care
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2025
LIC9099 (FAS) - (06/04)
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