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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073404422
Report Date: 06/04/2024
Date Signed: 06/04/2024 09:45:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2024 and conducted by Evaluator Brittany Crass
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20240411115557
FACILITY NAME:JACKSON, KAUSHAFACILITY NUMBER:
073404422
ADMINISTRATOR:JACKSON, KAUSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 215-5392
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY:14CENSUS: 7DATE:
06/04/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Kausha JacksonTIME COMPLETED:
10:00 AM
ALLEGATION(S):
1
2
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5
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9
Open alcoholic containers accessible to children
INVESTIGATION FINDINGS:
1
2
3
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5
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7
8
9
10
11
12
13
On 6/4/24, at 9:40AM, Licensing Program Analyst (LPA) Brittany Crass, conducted an unannounced subsequent complaint visit. LPA met with the licensee, Kausha Jackson, to discuss the above allegation. LPA previously toured the facility, reviewed facility records, and conducted interviews with the licensee, staff, and children.
The allegation is that the facility has open alcoholic containers accessible to children. Although bottles were observed, interviews indicated that children are not allowed in the dining area.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. This allegation is Unsubstantiated.
A notice of site visit was given and must remain posted for 30 days.
Appeal rights provided and discussed.
Exit interview conducted and report was reviewed with the licensee Kausha Jackson.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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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