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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 073404422
Report Date: 07/18/2025
Date Signed: 07/18/2025 09:27:37 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
06/04/2025 and conducted by Evaluator Ashley Hollinger
COMPLAINT CONTROL NUMBER: 02-CC-20250604082150
FACILITY NAME:JACKSON, KAUSHAFACILITY NUMBER:
073404422
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:0CENSUS: 0DATE:
07/18/2025
UNANNOUNCEDTIME BEGAN:
08:29 AM
MET WITH:Kausha JacksonTIME COMPLETED:
09:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
OTHER - Licensee forged the signature of the Landlord consent form to allow the Licensee to care for two additional school age children.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/18/2025, Licensing Program Analyst (LPA) Ashley Hollinger conducted an Unannounced Subsequent Complaint Investigation at Kausha Jackson’s Family Childcare Home. LPA met with Licensee, Kausha Jackson and explained the purpose of the investigation. During today’s inspection LPA observed two (2) toddler and one (1) school-ager. The finding for the above allegation was delivered during the inspection to which the Complainant alleges that Licensee forged the signature of the Landlord consent form to allow the Licensee to care for two (2) additional school age children.
During the investigation, LPA inspected the facility, reviewed relevant documentation, and conducted interviews with the Licensee and Complainant. Given the inconsistencies and lack of credible evidence to support the allegation, it was determined that this allegation may or may not have occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No Deficiency has been cited for this allegation. Exit interview was conducted with Licensee, Kausha Jackson and appeal rights were provided. A NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 CONSECTIVE DAYS.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Hollinger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
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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