Jackie's Hideaway 2

Type of visit: Required - 1 Year

At approximately 11:40 a.m. on 09/17/25 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. The facility was last visited on 09/27/24 for a prelicensing visit. It is a single story building with six (06) bedrooms, six (06) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) non-ambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Surveillance cameras are used in exterior areas. The front entrance was gated and unlocked from the inside. The front yard was maintained. At the front door, LPA observed postings for the house rules, facility sketch, facility license, COVID precautions, rights of resident councils, ombudsman contacts, confidential complaint contacts, and oxygen in use signs. Additional postings were observed for the emergency disaster plan, personal rights, rights of resident councils, and administrator certificates. A screening station at the front contained a visitor log and hand sanitizer. Walls, floors, windows, screens, and blinds were clean and in good repair. A fireplace near the main entrance was appropriately covered. The living room contained a television, reading materials, music materials, board games, exercise equipment, and furniture in good repair. Night lights were observed in the hallway. Two (02) closets in the hallway contained adequate amounts of fresh linens and hygiene supplies. A third closet was locked and contained extra cleaning supplies. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. Appliances were in good condition. At 11:50 a.m. the house telephone in the kitchen was called and deemed operational. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications were locked above the counter top. At approximately 12:00 p.m., Staff #1 (S1) and LPA conducted a medication review. All medications reviewed were maintained in the correct quantities. At approximately 12:30 p.m. a complete first aid kit was observed near the medications. The laundry room near the kitchen was locked and contained a washing machine and a dryer in working order as well as confidential files and an extra refrigerator for medications. Detergents were locked separately in a cabinet. At 12:35 p.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At 12:40 p.m. the dual purpose smoke and carbon monoxide detector in the hallway was tested and deemed operational. Smoke detectors were hard-wired and functioned simultaneously. At 12:45 p.m., three (03) out of three (03) fire extinguishers in the kitchen and hallways were observed to be fully-charged with receipts from 09/13/25 attached. The facility had six (06) bedrooms. Two (02) bedrooms were vacant. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were maintained in the locked position. Exit doors from rooms were unlocked. The facility had six (06) bathrooms. Bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:00 p.m. LPA measured the water temperature to be 108.2 degrees Fahrenheit in the private bathroom to Bedroom #2. Nine (09) out of nine (09) auditory alarms were on and functional. The seating area in the rear was shaded. The back yard also contained a gardened area. Emergency exit paths were free of hazards. The exit gate was unlocked. At 1:20 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. During today’s inspection, no immediate health or safety hazards were observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Prelicensing

At approximately 11:55 a.m. on 09/27/24 Licensing Program Analyst (LPA) Nicholas Reed conducted a prelicensing visit. LPA met with the administrator and disclosed the reason for the visit. Today’ prelicensing visit is conducted due to a Change of Ownership with residents in care. It is a single story building with six (06) bedrooms, six (06) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Surveillance cameras are used in exterior areas. The front entrance is gated and unlocked from the inside. The front yard is maintained. At the front door, LPA observed postings for the house rules, facility sketch, facility license, COVID precautions, rights of resident councils, ombudsman contacts, confidential complaint contacts, and oxygen in use signs. Additional postings were observed for the emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, and masks. Walls, floors, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately covered. The living room contained a television, reading materials, and furniture in good repair. At 12:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. At 12:25 p.m. the carbon monoxide detector in the hallway was tested and deemed operational. At 12:30 p.m. smoke detectors were tested and operational. At 12:35 p.m. LPA observed a fully-stocked first aid kit near the kitchen. It was purchased on 08/08/24. The facility has six (06) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were in the locked position. Exit doors from rooms were unlocked. The facility has six (06) bathrooms. Bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108.0 degrees Fahrenheit in the private bathroom to Bedroom #2. At 1:00 p.m. the house telephone was called and deemed operational. Nine (09) out of nine (09) auditory alarms were on and functional. The seating area in the rear was shaded. The back yard also contained a gardened area. Emergency exit paths were free of hazards. The exit gate was unlocked. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications were locked above the counter top. The laundry area was near the kitchen and contained a washing machine and a dryer in working order. Detergents were locked in a cabinet. At 1:20 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit. Component III was completed. During today’s inspection, no immediate health or safety hazards were observed. Pre-Licensing is complete and this facility has no deficiencies. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Dec 6, 2023