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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 032701408
Report Date: 10/10/2025
Date Signed: 10/10/2025 12:42:52 PM

Unsubstantiated


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
PUBLIC
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: 62DATE:
10/10/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cheryl TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff made inappropriate comments to resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced 10/10/25 to conduct a complaint investigation into the above allegation, LPA Met with Cheryl Boehme and Nataliya Regan and explained the purpose of the visit.

Physcial Plant Inspection and other concerns were addressed in a seperate case management with this date. Over two visits, LPA interviewed 5 staff and 8 residents in connection with the complaint. no consensus statement emerged, the LPA recived conflicting unwitnessed narratives that were not corroberated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No citations were given in connection with this visit, A copy of the appeal rights were left with the administrator. An exit interview was conducted, a copy of the report was read and given to the administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Noel Wolf Petersen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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