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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 10/07/2026
Date Signed: 10/07/2026 05:47:13 PM

Document Has Been Signed on 10/07/2026 05:47 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:
9162120275
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY: 70CENSUS: 59DATE:
10/07/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Cheryl Boehme, DesigneeTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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On 10/07/2026, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct the annual inspection. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. The Administrator of record was James Jordan, however his Administrator certificate expired. This facility was cited for this deficiency during a case management visit on 09/11/26. The facility will be cited for this repeat deficiency.

LPA began the inspection by comparing the LIC 500 with the Guardian roster to ensure that all staff had the appropriate background clearances. There were discrepances and this LPA and the Designee investigated by pulling staff files and looking individuals up in Guardian to verify if they were associated. 6 staff members were not. These deficiencies were cited on the LIC 809D page and civil penalties were assessed.

LPA conducted a walkthrough of the facility and observed 6 residents playing Bingo with 2 staff supervising. LPA inspected the kitchen which was inaccessible to residents in care. LPA observed enough food supply for 7-days nonperishable and 2-day perishable. Fire Extinguishers (17 in total) were last inspected on 11/18/25 by Cintas Fire Extinguisher Co. and were in compliance at the time of this inspection.

LPA inspected 4 resident rooms and all had the required furniture, furnishings and lighting to be in compliance at the time of this inspection. LPA interviewed 4 residents all stated they felt safe at this community, 3 out of 4 stated they liked the food.

LPA inspected the Medication Room.  LPA reviewed administration and destruction procedures with staff. LPA emphasized that medications could not be removed from their original container and stored in another.
Lisa Rios
Kimberly Viarella
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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)
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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: 10/07/2026
NARRATIVE
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Waivers are required when sending medications out with a resident. LPA also inspected the first aid kit to
ensure it had all the required elements. It too was in compliance.

The following materials were posted in the facility: "If You See Something, Say Something" and Ombudsman contact information posters, Resident Rights, grievance policy, calendar of activities, and facility license.
 
The Designee and the LPA inspected the exterior of the facility.  All screens and gutters were in good repair at the time of this inspection. There were fenced in / courtyard areas, along with a long front porch for all residents to enjoy.  

LPA then conducted a review of 3 resident files and 3 staff files. The 3 resident files were complete and in compliance at the time of this inspection. Of the 3 staff files reviewed, all 3 did not have the required training hours for annual training and dementia care. These deficiencies were cited on the LIC 809D page.

According to the California Code of Regulations, Title 22, no other deficiencies were cited during today's visit a copy of this report was provided, along with APPEAL RIGHTS, and an exit interview was conducted with the Designee.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 10/07/2026 05:47 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/07/2026 at 04:40 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: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 6 staff members on the LIC 500 were not assocaited to the facility poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2026
Plan of Correction
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The Desginee will be providing the unassociated with live scans to take and get fingerprint cleared tomorrow 10/08/26. Proof of this will be emailed to Kimberly.viarella@dss.ca.gov by the close of business on 10?08/26
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2026 05:47 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/07/2026 at 04:40 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: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 3 out of 3 staff files were reviewed and they did not contain the required annual training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2026
Plan of Correction
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Designee stated that all annual training will be conductedd for all caregivers and medtechs, tracked accordingly, and transcipts will be submitted to Community Care Licensing by 11/20/26 at CCLASCPSacramentoSouth@dss.ca.gov.
Type B
Section Cited
HSC
1569.626(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 3 out of 3 files reviewed did not contain the required hours for their initial or annual dementia care training. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2026
Plan of Correction
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Designee stated that going forward, all new hires will complete their 12 hours of dementia care training before providing any direct care. The facility will send any new hire dementia care training to CCL at CCLASCPSacramentoSouth@Dss.ca.gov by 11/20/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2026 05:47 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 10/07/2026 at 05:10 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: 10/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405
Based on record review and interview the Administrator of record and the 2 designess at the facility today do not have current RCFE certificates. Also the Admin or record has not been keeping scheduled hours at the facility. This poses a potential threat to the health, safety and personal rights of residents in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Darrell Price, the current Administrator of Record does not have an active Administrator's certificate. During the case management visit on in September, Price stated that he woudl be submitting the paperwork for the change of administrator. That had not been completed prior to this visit. This poses a potential threat to the health, safety, and personal rights, of residents in care.
POC Due Date: 10/16/2026
Plan of Correction
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Designee stated that all change of Administrator paperwork will be submitted by 10/16/26 to Kimberly.viarella@dss.ca.gov.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Kimberly Viarella
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
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