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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 08/28/2025
Date Signed: 08/28/2025 08:00:54 PM

Document Has Been Signed on 08/28/2025 08:00 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: 61DATE:
08/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:24 PM
MET WITH:Cheryl BoehmeTIME VISIT/
INSPECTION COMPLETED:
08:00 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 8/28/25, at 10:00am Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced met Cheryl Boehme and Nataliya Regan to explain purpose of the visit to conduct an annual inspection. Jackson hills assisted living llc is a 70 bed facility with a current census of 61, they are accepting clients over 60, with the restricted conditions of diabedes and dementia for which they have facility wide waivers.

The Facility plant was inspected including the bedrooms, bathrooms, kitchen, storage areas, exteriors, and evacuation routes. The Facility is clean, traffic areas are well lit and unobstructed. Bedrooms have all the required furniture and furnishings, feel very lived in and comfortable. Bathrooms have functional hardware, water temperature is in adequate deliverable range of temp. storage areas are adequately locked for sharps, medications and toxics, proper supervision is provided when unlocked for the risk to dementia care residents. MAR is not totally congruent with the kind and quantity of medications for the residents, addressed as part of the complaint. Food service is not prepared with prevention mechanisms to relive dust and other potentialy hazzardus particles while there is a renovation taking place during the meal service, address as part of the complaint.

LPA observed 2 bedrooms have to access another bedroom to get to thier designated bathroom. It would appear to be every exterior facing bedroom is set up that way. LPA will cross report to fire code to double check it.
LPA observed meds are currently being prepoured for medication service and the facility is trying to get more uptake from the residents to switch to a blisterpack version of thier medications.
LPA observed some residents keep medications in thier own rooms stored in a way that would be accessible to wandering dementia folks in care, the facility will provide some kind of alternate storage solution(lockable boxes/lockable drawers/ect) to keep the wandering dementia folks safe from consuming those.

Continued on C Page.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
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: 08/28/2025
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
26
27
28
29
30
31
32
LPA reviewed 5 staff files, they contained adequate and up to date recrods of backround checks, criminal clearances, firstaid/cpr, regular yearly and onboarding training as well as additional training requirements specific to dementia and diabedes care.

LPA reviewed 5 client files, they contained adequate and up to date records of signed admission agreements, medical and mental health preappraisals as necessisary, the house rules and personal rights notifcations, additional notifications regarding camera policies, as well as a record personal cash and property under bond at the facility.

LPA reviewed the admission agreement, program design, surety bond, staff roster, resident roster, facility sketch with evacuation routes, required posters, but not the evacuation control plan and the infection control plan.
The documents were found to be present and up to date.

The LPA interviewed 5 clients and 5 staff.

Citations were issued on a following d- page, a copy of the appeal rights were provided. a Copy of the report was read and given to staff.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST 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
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/28/2025 08:00 PM - It Cannot Be Edited


Created By: Noel Wolf Petersen On 08/28/2025 at 07:30 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
, 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 45 out of 60 med containers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
1
2
3
4
No POC Required, facility will convince as many people as possible to switch to blister, otherwise pour medications in the immediate presence of the person reciving the med.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Noel Wolf Petersen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
Page: 4 of 4