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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 032701408
Report Date: 09/11/2026
Date Signed: 09/11/2026 03:39:04 PM

Document Has Been Signed on 09/11/2026 03:39 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: 58DATE:
09/11/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Cheryl Boehme, DesigneeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 09/11/26, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct a follow-up case management visit regarding complaint #27-AS-20260508151510. LPA identified herself upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator, James Jordan. Jordan was not at the facility. LPA met with Designee, Cheryl Boehme, and a brief meeting followed.

During the course of the above investigation, the Department observed deficiencies that will be addressed during this visit. On 06/23/26 the Department learned that the Licensee did not ensure that all employees were background cleared as required and a caregiver (S1) was not background cleared and associated to this facility.  The Designee produced live scan documentation and a letter from the Department of Justice, but they could not produce a clearance letter from Community Care Licensing (CCL) showing that S1 was cleared to work at this facility. Upon further investigation, this LPA learned that there had been a mistake on the live scan form completed and that CCL had sent a letter to S1 requesting additional information.  That information was not received and their application could not be processed. The deficiency has been cited on the LIC 809 D page. An immediate civil penalty of $500.00 was assessed. 

Based on record review and an interview with the Designee and Care Coordinator, the Licensee did not ensure that a written record of the care R1 was to receive was developed and maintained. During record
review the Care Coordinator was not able to produce a pre-appraisal or an individualized care plan for R1 and instead provided /referenced a task list identifying bathing, toileting, dressing, and personal hygiene as "requires assistance." This task list did not identify or document what assistance R1 required, how the facility would meet those needs, or other individualized care needs as required by the California Code of
Lisa Rios
Kimberly Viarella
DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2026
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.

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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: 09/11/2026
NARRATIVE
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Regulations.  LPA reviewed a signed admission agreement for R1 dated 12/02/25 and R1 should have had care plan in place prior to or within the first 2 weeks after moving into the community. This resident's file was also missing a signed Physicians Report (LIC 602). The resident's file was incomplete. This deficiency was cited on the LIC 809 D page. 

Based on record review and interviews with the Designee and Care Coordinator on 05/11/26, the Licensee did not ensure that reporting requirements were followed as a death report for R1 was not submitted to Community Care Licensing by the required deadline.  Designee and Care Coordinator stated that they did not think that they had to submit a death report if a resident expired in the hospital.  LPA clarified that all resident deaths needed to be reported to Community Care Licensing.  This deficiency was cited on the LIC 809 D page.

During this visit based on a review of records and interviews with Designees Nataliya Regan and Cheryl Boehme, this LPA learned that neither individual had a current RCFE Administrator's certificate. The Administrator of record, James Jordan, also did not have a current RCFE Administrator's certificate. This LPA checked the state website for "pending approval" for all certificates being renewed, and both Boehmen and Jordan's names were missing. Reagan informed this LPA that they were moving out of the state at the end of the month and therefore did not renew their certificate. This deficiency has been cited on the LIC 809 D page. Also of note, James Jordan did not list their scheduled hours on the LIC 500 as required.

Regarding staffing, this LPA conducted 4 interviews today; 3 residents and 1 staff member. 2 out of 2 people interviewed stated that they felt staffing was not an issue. One of the 2 who said that there had been difficulty finding staff on the PM shift last winter stated that has not happened in a long time. R2 stated, "Now there is always someone in the med room at night."

LPA learned from Reagan that currently they have 2 caregivers and 1 medication technician along with 2 activities staff for each AM shift. Activities staff have caregiver training and can jump in when needed. In addition, Regan and Boehme also work day shifts and provide extra support. Regan stated that they have a new hire for the PM shift starting soon and they are actively seeking someone to work a mid-shift. That will ensure that there is always adequate coverage during meals and they will be able to assist with showers.
NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Kimberly Viarella
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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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: 09/11/2026
NARRATIVE
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This LPA observed an exercise class this morning upon arrival with 15 residents being led by 2 activities staff. This LPA also observed 2 care staff assisting residents throughout the day. At lunch this LPA observed 27 residents in the dining room being served lunch by one lunch aide and a kitchen staff member. LPA also observed a medication technician preparing medications for residents.

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

DATE: 09/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:39 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/11/2026 at 02:18 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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87411(g)(1)

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Personnel Requirements: (g) Prior to employment...criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations...
The Licensee did not ensure the above regulation was not met as evidenced by:

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The Designee, Cheryl Boehme stated that
he staff worker (S1) was sent to get their background clearance done and will not return to work until they have been cleared.

This POC has been cleared.
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Based on record review and interview S1 began but did not complete their background clearance process. This poses an immediate threat to the health safety and personal rights of residents in care.
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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: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:39 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/11/2026 at 02:24 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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2026
Section Cited
CCR
87506(a)

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Resident Records- (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...available to facility staff and to licensing agency staff.
The licensee did not ensure the above requirement was met as evidenced by:
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The Designee stated that she will conduct a file audit to ensure that all resident files are complete. This will be done by 11/18/26. The Designee will provide a status on 11/26 by emailing kimberly.viarella@dss.ca.gov
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Based upon record review R1 did not have a pre-appraisal, complete care plan or a signed LIC 602 on file when this LPA requested them. This posed a potential threat to the health, safety, and personal rights of residents in care.
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Type B
09/30/2026
Section Cited
CCR87211(a)(1)(A)

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Reporting Requirements -(a) ...shall furnish to the licensing agency...(1) A written report shall be submitted ...seven days...(A) Death of any resident from any cause regardless of where the death occurred...
The Licensee did not ensure the above regulation was not met as evidenced by:
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Boehmne signed an attestation that she understood the contents of CCR 87211(a)(1)(A) and provided this LPA with a copy.

This POC has been cleared.
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Based on record review and interview, a death report for R1 was not sent to CCL. This poses an potential threat to the health, safety, and personal rights of residents in care.
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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: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/11/2026 03:39 PM - It Cannot Be Edited


Created By: Kimberly Viarella On 09/11/2026 at 02:44 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: 09/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2026
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties (a)...qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities...
The Licensee did not ensure the above regulation was not met as evidenced by:



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The facility will provide licensing with an updated LIC 200 and LIC 500 with the name and scheduled hours for a currently certified RCFE Administrator. These forms will be submitted to Licensing by fax or email at
CCLASCPSacramentoSouthRO@dss.ca.gov
with a copy to
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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.
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Kimberly.viarella@dss.ca.gov

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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: 09/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2026


LIC809 (FAS) - (06/04)
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