Jackson Hills Assisted Living

Type of visit: Case Management - Deficiencies

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 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. 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.the state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Sep 11, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 18, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Sep 30, 2026

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: 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.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 28, 2026

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: ( 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.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: 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 Kimberly.viarella@dss.ca.gov

Allegation investigated: Staff are not responding to resident council concerns.

On June 4, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a follow-up investigation and to deliver findings relating to the allegations noted above. LPA met with administrator-designee, Natalya Regan (AD), and stated the purpose of the visit. The investigation into the above allegation consisted of interviews and record reviews. Interviews with residents showed that the facility does not give written responses to the concerns they bring up during Resident Council meetings. Residents stated that they have been raising the same issues for a long time and have not received any written follow up from staff. {1 of 2} Substantiated Staff interviews confirmed that they receive the Resident Council meeting notes and try to talk to residents about the concerns. Per staff interview, they response in writing usually the next day; however, they stated that they do not keep a copy of the written responses for their records. Staff stated they provided copy of the written responses to the president of the resident council. The provided copy of responses from May 15, 2026 and April 9, 2026. According to staff, they do not keep copy of their written responses they provide to the resident council president. Facility does not have other documentation to prove that written responses were provided to residents. Records explains that since last year, the Resident Council has been submitting meeting minutes to the facility, but the facility has not provided any written response or met the 14 day deadline. Records also shows that many dining concerns listed by residents—such as burnt or cold food, last minute menu changes, inconsistent menus, lack of variety in fruits and vegetables, and not enough staff in the dining room—have continued for a long time without being fixed. Records further notes that the facility makes changes to the menu or meal options without clear communication to residents, which causes confusion. Based on interviews and record reviews, the preponderance of evidence is met which shows that the facility is not responding to Resident Council concerns as required. Therefore, this allegation is substantiated. Deficiencies were being cited per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8. Plan of correction and appeal rights were discussed during exit interview with AD. A copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20260403145341

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.157(c) · Plan of correction due date: Jun 11, 2026

If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement is not met as evideced by: based on interviews and record reivews, facility do not provide written responses to the residents within 14 days. This poses a potential health, safety, and/or personal rights risks to persons in carethe state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Per discussion, the administrator will submit a written statement of understanding of the regulation HSC 1569.157 relating to the regulatory requirement regarding resident council by POC due date.

Allegation investigated: Facility staff are not providing adequate food service to residents in care.

On June 4, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived at this facility unannounced to conduct a follow-up investigation and to deliver findings relating to the allegations noted above. LPA met with administrator-designee, Natalya Regan (AD), and stated the purpose of the visit. The investigation into the above allegation consisted of interviews, record reviews and observation. During interviews, several residents said the food is often cold, burnt, undercooked, or poor in quality. They also reported that the menu is repetitive and that there are not enough choices, especially for people with special diets like diabetes. {1 of 2} Substantiated A review of activity calendars from October 2025 through February 2026 showed a wide variety of daily activities, including exercise groups, bingo, music programs, church services, art and craft therapy, dog therapy, van rides, nail care, table games, card games, and resident council meetings. Observations made on 12/19/25, 2/4/26, 2/19/25, 4/10/26, and 6/4/26 showed activities taking place, with residents participating in group games, watching TV, and using materials in the activity area. On 2/4/26, the activity room was full of residents, and the activity staff showed this LPA videos of several table games completed earlier that day. Activity calendars were observed to be posted in the lobby and activity room. Based on interviews, records reviewed, and direct observations, there is no evidence to support the allegation that staff are not providing activities to residents in care. Therefore, the allegation is unfounded. Report was reviewed during exit interview with AD and a copy of this report was provided. Staff interviewed explained that the previous kitchen supervisor did not order food supplies on time, which causes the facility to run out of basic items such as juice, creamer, and butter. Staff also stated that when they report problems to management, their concerns “fall on deaf ears.” Photos reviewed showed examples of burnt or poorly prepared meals recently served to residents. Reviews of records, including resident council meeting notes from 2025 to 2026 showed ongoing issues over many months, including cold food, small portions, greasy meals, late meal service, lack of variety, unclear menu changes, and not enough staffing in the dining room. In addition, observation by LPA Wolf Peterson from August 2025 showed long delays in meal service, low calorie meals, flies in the kitchen, and contractors entering the kitchen during meal service without barriers, raising safety concerns. During an interview with management staff, they stated they have been gradually addressing these issues and will continue working on any food service concerns moving forward. While the efforts were noted, the evidence still shows the facility has not consistently met residents’ food service needs. Therefore, this allegation is substantiated. Deficiencies were being cited per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8. An immediate civil penalty of $1000 is hereby assessed due to a repeat violation of the regulation CCR 87555(a). Failure to make and submit corrections may result in additional civil penalties. Review of this report and discussion of plan of correction were conducted at the exit interview with AD. A copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jun 4, 2026 · control 27-AS-20251008111928

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jun 11, 2026

The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... This is not met as evidenced by: Based on interviews, record reviews and observation, evidence showed that facility were not consistent in meeting resident food service needs. This poses a potential health, safety, and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2026

Plan of correction: Per discussion, the administrator will submit a written statement of understanding of the regulation cited relating to the regulatory requirement for food service by POC due date. Per interview, facility is currently addressing the ongoing concerns of their residents and will continue to do so.

Allegation investigated: Staff are not properly advertising their license number. Staff are not properly posting the notifications required by licensing.

On 12/19/2025, Licensing Program Analyst, Arvin Villanueva (LPA), conducted an unannounced complaint investigation visit to the facility to investigate the allegations noted above. In this visit, LPA conducted a facility tour, interviewed staff and resident, and reviewed records and the facility’s website. The investigation into the allegation that staff are not properly advertising their license number consisted of facility observation, interviews and review of facility’s website. During the facility tour, LPA observed multiple postings throughout the building. The Facility License was observed posted on the wall behind the reception office. This LPA stood in front of the reception desk, where residents and guests would stand. From this perspective, LPA can see the Facility License, but it is located far enough that the facility number is not legible. Note that this LPA does not wear reading glasses and has normal vision of about 20/20. {1 of 2} Substantiated Interviews with staff confirm that the facility website does not include the Facility’s license number. LPA reviewed the facility’s website, https://jacksonhillsassisted.com/, and confirmed that the facility license number is not displayed on any of the webpages Based on the information obtained through observation, interviews, and website review, the allegation that staff are not properly advertising their license number is SUBSTANTIATED. ********************************************************* The investigation into the allegation that staff are not properly posting the notifications required by licensing consisted of facility tour and interviews with staff and residents. During the facility tour, LPA observed several required postings throughout the building. The Personal Rights poster was observed in the hallway immediately after the entrance/lobby area, across from the reception and medication room, leading toward the activity area. The facility license was observed posted on the wall behind the reception office. LPA also observed an Ombudsman poster in the hallway near the entrance/lobby area and another Ombudsman poster posted in the hallway leading to the dining area near the kitchen. LPA observed the Rights to Resident Council posted on a cork board in the activity area. Activity calendars were posted at the entrance/lobby area and in the activity area. The Administrator stated that each resident receives a copy of the activity calendar monthly, and newsletters are provided to family members. Paper copies of newsletters are also available in the lobby for residents to read. LPA additionally observed “No Smoking” signage due to oxygen use, as well as Oxygen Use signage posted at the doors of residents using oxygen. However, LPA did not observe the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) posted anywhere in the facility during the visit. Interviews with staff confirms that the RCFE Complaint Poster is not currently posted anywhere in the building. Interview with a resident confirmed they know the location of the Ombudsman poster but did not reference seeing the RCFE Complaint Poster. Based on the information obtained through observation and interviews, the allegation that staff are not properly posting the notifications required by licensing is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Nataliya Regan and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 27-AS-20251214231119

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87206(a) · Plan of correction due date: Dec 31, 2025

In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence. This requirement is not met as evidenced by: Base on observation, interviews and review of facility's website, the licensee did not ensure their facility license number was included in their website. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Per discussion, the licensee will include the facility license number in the facility's website. Photo of the website showing the license number will be submitted to the Department by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Dec 31, 2025

Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Through observation and interviews, the licensee did not ensure their complaint poster is posted at all times. This poses a potential health, safety, and personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2025

Plan of correction: Per discussion, Administrator agreed that photo of the require poster, posted on the facility wall, will be submitted to the Department by POC due date.

Allegation investigated: Facility staff made inappropriate comments to resident.

Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced 10/10/25 to conduct a complaint investigation into the above allegation, LPA Met with Cheryl Boehme and Nataliya Regan and explained the purpose of the visit. Physcial Plant Inspection and other concerns were addressed in a seperate case management with this date. Over two visits, LPA interviewed 5 staff and 8 residents in connection with the complaint. no consensus statement emerged, the LPA recived conflicting unwitnessed narratives that were not corroberated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No citations were given in connection with this visit, A copy of the appeal rights were left with the administrator. An exit interview was conducted, a copy of the report was read and given to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 10, 2025 · control 27-AS-20250821112407

Type of visit: Case Management - Deficiencies

on 10/10/25 at 11:30am Licensing Program Analyst, LPA, Noel Wolf Petersen arrived unannounced to the facility to conduct a case management in association with a previous complaint. LPA met with cheryl Boehme and Nataliya Regan, and explained the purpose of the visit. The Physical inspection included but was not limited to, kitchen, exteriors, evacuation routes, common areas, storage areas, resident bedrooms, and resident bathrooms. facility is clean, traffic areas are unobstructed and well lit. The bathrooms have functional hardware, the water temperature is delivered between 105-120, metered at 3 locations at varying distances from the heaters. Resident bedrooms have all required furniture and furnishings. Exteriors have no torn/bent/missing screens, its clean and there is space for activities, some exterior gates have locks for various periods of time, LPA gave guidance that the designated fire exits are to remain unlocked. LPA observed the storing of medication outside of its orginal container in the med room, citation was issued. Evacuation drill log was checked, it happens at least once a quarter. Kitchen repairs are almost complete, about 50% of the floor still has to be replaced, a plain exists to provided uninterrupted basic services during this repair. 3 residents interviewed, 3 staff interviewed. no staff files, no client files were reviewed. procedures for prn documentation, and med refusal documentation are improved in their description to the LPA but not yet implemented. LPA gave the guidence that those procedures as described should be added as an ammendum to the program design and submitted to the department for review. One citation was issued in connection with the visit. a copy of the appeal rights was given to the administrator. a exit interview was conducted, a copy of the report was read and given to the administrator.the state’s words, verbatim · CDSS document, Oct 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Oct 11, 2025

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications...:(5) Each resident's medication shall be stored in its originally received container. No medications shall be t ansferred between containers.This requirement was not met as evidenced by: Observationby the LPA of (10+) clients medicaitons being prepared for the mid day pass outside of the immedate presence of the clients in seperate contatiners from the orignial, and 1(warfrin) being stored outside its orignal container for the evening pass. This poses a health, safety, personal rights risk to the clients in care.the state’s words, verbatim · CDSS document, Oct 10, 2025

Plan of correction: The facility is going to stop it's practice of prepoured medications immediately, and submit a plan to the LPA as to how a timely med pass procedure will occur without prepouring the medications. The plan can be submitted to the LPA in a week, 10/17/25.

Allegation investigated: Facility staff are not providing residents medication as prescribed. Facility staff do not provide adequate food service to residents in care.

on 8/28/25, at 10:00 Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced met Cheryl Boehme and Natalyia Regan to explain purpose of the visit to open complaint investigation. Observation of services(2pm Medication pass and lunch/dinner meal service). MAR confirms that in at least one instance a medication(heart medication) was not delivered to a resident in time with thier perscribed order for a period of 3 days. Administration does not have a record of increased staff monitoring the residents who were between medications. Records are not detailed enough to account refusals and PRNs, status of med delivery(availible at pharmacy/in transit/ect). LPA is providing guidance that to meet the nessisary reporting requirements and to reach the level of detail in record keeping to be compliant with titlle 22 state regulation, a single staff is not adquate to meet the needs of 61 people let alone 70 in a safe and comfortable manner. Continued on C Page. Substantiated Meal services are supplied to 61 residents, from a staff of 3-5, one to two chefs and 2-4 handlers. The kitchen is in some state of renovation where potentialy inedible or toxic matierals might enter the food during preperation. LPA observed work being done durring the lunch and service, with contractors bringing matierials into the work area through the food prep area. LPA observed the dinner meal service was not provided as described on the menu(forgotten marinara sauce for a raviolli dish), which resulted in some substantial nutrient and calorie content loss. Kitchen staff recive a lot of complaints about all meal services, LPA provided guideance that there seems to be bottlenecks coming from hardware and staffing limitations ( in the dinner service specificly with 1 chef, 2 handlers) in the capacity to great deal of difficulty in providing 61 meals, request handling for alternate menu items, adjustments for perscriptive diets, ect. Based on LPAs observations, interviews, observations, and record reviews which were conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Per title 22 citations were issued, on a following D Page. Appeal rights were provided. An exit interview was conducted, and a copy of the report was read and given to the administrator.the state’s words, verbatim · CDSS document, Aug 28, 2025 · control 27-AS-20250821112407

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Aug 29, 2025

87465 Incidential Medical and dental Services (c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided...: (2) Once ordered by the physician the medication is given according to the physician's directions. The requirement was not met as the result of: record review of the mar showing a period of 3 days where neither of the perscribed heart medications were not availible to the resident for reasons unknown This poses an immediate health and saftey risk to persons in care.the state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: The Facility will make sure medication is availible to the residents as perscribed, including having detailed records that reflect a status the medication is in if it's not in the care of the facility, including what will be done to keep the resident safe when medication is in a nondeliverable state. a sample Copy of the new record keeping process, a detailed documentation for the refusal process, a detailed documentation for the prn process, will be given to the LPA end of buisness friday, 8/29/25.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(a) · Plan of correction due date: Aug 29, 2025

87555 General Food service requirements (a) the total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner. The requirement Was not met as evidenced by: LPA's observation of the kitchen in a state of renovation where particles and workers could travel into the food served during meal preperation. This poses an immedate risk to health to persons in carethe state’s words, verbatim · CDSS document, Aug 28, 2025

Plan of correction: No plan of correction needed. The Facility set up a barrier between the two work areas. The barrier shall be maintained for the period of the work being done, the facility will invest resources in its maintaince, and the maintanience in a pest free envionment during the work period.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 8/28/25, at 10:00am Licensing Program Analyst (LPA) Noel Wolf Petersen, arrived unannounced met Cheryl Boehme and Nataliya Regan to explain purpose of the visit to conduct an annual inspection. Jackson hills assisted living llc is a 70 bed facility with a current census of 61, they are accepting clients over 60, with the restricted conditions of diabedes and dementia for which they have facility wide waivers. The Facility plant was inspected including the bedrooms, bathrooms, kitchen, storage areas, exteriors, and evacuation routes. The Facility is clean, traffic areas are well lit and unobstructed. Bedrooms have all the required furniture and furnishings, feel very lived in and comfortable. Bathrooms have functional hardware, water temperature is in adequate deliverable range of temp. storage areas are adequately locked for sharps, medications and toxics, proper supervision is provided when unlocked for the risk to dementia care residents. MAR is not totally congruent with the kind and quantity of medications for the residents, addressed as part of the complaint. Food service is not prepared with prevention mechanisms to relive dust and other potentialy hazzardus particles while there is a renovation taking place during the meal service, address as part of the complaint. LPA observed 2 bedrooms have to access another bedroom to get to thier designated bathroom. It would appear to be every exterior facing bedroom is set up that way. LPA will cross report to fire code to double check it. LPA observed meds are currently being prepoured for medication service and the facility is trying to get more uptake from the residents to switch to a blisterpack version of thier medications. LPA observed some residents keep medications in thier own rooms stored in a way that would be accessible to wandering dementia folks in care, the facility will provide some kind of alternate storage solution(lockable boxes/lockable drawers/ect) to keep the wandering dementia folks safe from consuming those. Continued on C Page. LPA reviewed 5 staff files, they contained adequate and up to date recrods of backround checks, criminal clearances, firstaid/cpr, regular yearly and onboarding training as well as additional training requirements specific to dementia and diabedes care. LPA reviewed 5 client files, they contained adequate and up to date records of signed admission agreements, medical and mental health preappraisals as necessisary, the house rules and personal rights notifcations, additional notifications regarding camera policies, as well as a record personal cash and property under bond at the facility. LPA reviewed the admission agreement, program design, surety bond, staff roster, resident roster, facility sketch with evacuation routes, required posters, but not the evacuation control plan and the infection control plan. The documents were found to be present and up to date. The LPA interviewed 5 clients and 5 staff. Citations were issued on a following d- page, a copy of the appeal rights were provided. a Copy of the report was read and given to staff.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff coerced a dementia resident into signing legal documents.

On 1/1/7/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA met with Cheryl Boehme and stated the purpose of this visit. The investigation into the allegation that facility staff coerced a resident (R1) with dementia into signing legal document consisted of interviews and document reviews. Interview with an involved party (W1) confirmed that they were contacted by the Ombudsman to help with R1's situation. W1 described R1 as coherent during the document signing, able to recognize people with some reminders, and able to clearly express intentions despite having dementia. R1 executed a power of attorney for medical rights, with those rights being returned to R1 until a new fiduciary was appointed. W1 mentioned that R1 had concerns about financial exploitation by previous fiduciaries. W1 also confirmed that facility staff (S2), was present as a witness during the signing to ensure transparency. W1 emphasized that there was no evidence of coercion in R1's decision-making. {1 of 2} Unsubstantiated Interview with S1 who noted that R1, suffering from dementia. Furthermore, there is an ongoing investigation by Adult Protective Services (APS) concerning R1’s property and allegations against R1’s Power of Attorney (POA), regarding financial mismanagement. The Ombudsman intervened to protect R1’s bank account by making it solely under R1’s name, excluding POA and another individual, while the next court hearing is scheduled for January 2025. Additionally, other interviews indicated that facility staff acted accordingly to protect R1 when allegations of elder abuse were made against R1’s POA. Document review revealed that a judge had ruled that the documents signed under the Ombudsman’s direction at Jackson Hills were invalid, and those documents prepared in 2022 were still considered valid. A further document review confirmed that R1 has advanced dementia and was assessed as no longer competent to make medical or financial decisions independently. R1 was determined to need an attorney or legal agent present for any decision-making. Although R1 suffers from advanced dementia, the signing of legal documents was deemed necessary by the Ombudsman due to allegations of elder abuse against R1’s POA. Interviews revealed that facility staff acted as witnesses during the signing process and were following the Ombudsman’s instructions to ensure R1's safety and protection. The facility was protecting R1 from the allegation of financial exploitation and ensured that no coercion occurred during the signing of the legal documents. There is no clear evidence to support the claim that facility staff coerced R1 into signing the documents, therefore, the allegation was deemed UNSUBSTANTIATED. Note that an unsubstantiated finding means 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. Based on today’s visit, no deficiencies are being cited. Exit interview was conducted with Cheryl Boehme and a copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 27-AS-20241007134422

Type of visit: Case Management - Other

On 1/17/25, Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced Case Management - visit at this facility to continue with the post-licensing Inspection visit initiated on 12/19/24. LPA met with aCheryl Boehme and stated the purpose of the visit. This LPA continued with facility visit to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Facility is fire cleared for 70 residents who are non-ambulatory, 4 of which may be residents who are bedridden. Facility is approved to retain/accept 15 residents who are receiving hospice care. LPA reviewed 5 resident files (R1 - R5). Reviews include review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. No issues were noted at this time. LPA reviewed 3 staff files (S1 - S3) which include review of background clearance, First Aid/CPR certificate, Health Screen, Initial and Ongoing Training. Facility conducts quarterly disaster drill. Facility has a dementia and infection control plan in place. Based on today's visit, no deficiencies are being cited. Exit interview was conducted with Cheryl Boehme and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 17, 2025

Type of visit: Post Licensing

On 12/19/2024, at 2:30pm, Licensing Program Analyst (LPA), Arvin Villanueva arrived unannounced to conduct a post-licensing evaluation. A pre-licensing visit was conducted on 9/10/24 for Change of Ownership (CHOW). LPA met with James Jordan and Nataliya Regan and explained the purpose of the visit. LPA and Nataliya Regan inspected the physical plant of the facility to ensure compliance of Title 22 regulation. Facility has a 70-resident capacity for Assisted Living residents, 4 of which is fire cleared for bedridden residents. Facility is a one-story building located in a residential neighborhood. During this visit, LPA observed the Activity Director taking some residents to the store. Also during physical inspection, LPA observed staff going in resident rooms providing water. Some residents were observed to be playing cards in the activity area. Temperature in the hallways were observed at 70 degrees F. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. LPA did not observe bodies of water at this time. LPA observed deck to be newly renovated. LPA inspected 4 resident units. Each unit is fire cleared for non-ambulatory residents. The inspected resident units were observed to be furnished with adequate storage for resident belongings. Each resident unit is equiped with a bathroom.. All bathrooms inspected have working toilets, wash basins and full baths have showers. There are grab rails next to both the toilets and the showers as well as nonskid flooring. Water temperature: Water temperature in 4 selected bathroom (in a resident units) were measured between 116 and 118 degrees F. In 4 of 4 resident units were observed to have a smoke detector and carbon monoxide detectors. Additionally, facility is equipped with sprinkler system. {1 of 2} Poisonous substances, sharp objects and other dangerous items were observed to be properly stored, locked, and inaccessible to residents in care. . Facility employs an activity director. LPA observed activity calendar available for residents. LPA observed an activity area in the facility. Outside activity area is properly enclosed. Doors leading to the outside have auditory devices to monitor exits. Kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils were observed to be locked and inaccessible to residents. Food supply was adequate and stored in kitchen refrigerator, freezer and 2 walk-in pantries and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Stove burners and oven were observed to be in good repair. Temperatures in refrigerator and freezer were observed to be within regulatory standard. Menu was observed and available to residents in care. Due to insufficient time, this post licensing visit will require a continuation. The Department will return at a later date to continue the inspection. Exit interview was conducted and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Prelicensing

On 9/10/2024, at 10:00am, Licensing Program Analyst (LPA), Arvin Villanueva arrived unannounced to conduct an inspection to the above facility for purpose of a pre-licensing evaluation. This pre-licensing is for Change of Ownership (CHOW). LPA met with James Jordan, Nataliya Regan, and Cheryl Boehme, and explained the purpose of the visit. LPA, Cheryl Boehme, and Nataliya Regan inspected the physical plant of the facility to ensure compliance of Title 22 regulation. LPA observed 8 random resident units, the activity room, dining room, kitchen, laundry, and outdoor areas. Facility has a 70-resident capacity for Assisted Living residents, 4 of which is fire cleared for bedridden residents. Facility is a one-story building located in a residential neighborhood. Outdoor passageways, walkways, driveways, and steps are free from obstructions. LPA did not observe hazards, such as ladders, gardening tools and/or motorized equipment in the front, back and/or side areas of the facility. LPA did not observe bodies of water at this time. Bedrooms Residents: LPA inspected 8 resident units. Each unit is fire cleared for non-ambulatory residents. The resident apartments/units are spacious and will easily accommodate the residents furnishings. The inspected resident units were observed to be furnished with adequate storage for resident belongings. Bathroom: Each resident unit contain private bathroom. All bathrooms inspected have working toilets, wash basins and full baths have showers. There are grab rails next to both the toilets and the showers as well as nonskid flooring. Toxins and Chemicals: Toxins and chemicals for cleaning are properly stored, locked, and inaccessible to residents in care. . Water temperature: Water temperature in a randomly selected bathroom (in a resident units) were measured at 112 and 119 degrees F. Activities: Facility employs an activity director. LPA observed activity calendar for residents' use. LPA observed an activity area in the facility. Outside activity area is properly enclosed. Doors leading to the outside have auditory devices to monitor exits. Food Service and Kitchen: Kitchen area and dining area were inspected and observed to be in good repair. Knives, cutlery and other sharp kitchen utensils are in locked and inaccessible to residents. Food supply was adequate and stored in kitchen refrigerator and walk-in pantry and consists of the following: A variety of fresh and canned fruit, vegetable and meat food items. Stove burners and oven were observed to be in good repair. Temperatures in refrigerator and freezer were observed to be within regulatory standard. Menu was observed and available to residents in care. Smoke Detectors/Carbon Monoxide: Each inspected resident units were observed to have a smoke detector and carbon monoxide detectors. Additionally, facility is equipped with sprinkler system. Smoke detectors are hardwired and interconnected, and they are fully operational. Facility conducts quarterly disaster emergency drills. Medications and First-Aid Kit: Resident medications were observed to be stored in the medication room and observed to be locked and inaccessible to residents in care. First aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and manual which are stored in locked cabinet, available for staff use but inaccessible to clients. Facility, Residents & Staff Files: Applicant will not be handling cash resources of residents. Records of staff and residents are stored in a locked room and accessible to staff. LPA reviewed 5 resident files and 5 staff files. LPA provided licensee the form LIC311F (Records to be Maintain at the Facility - RCFE) to ensure facility maintains required records at all times. Component III: Conducted at the Pre-Licensing visit, on 9/10/2024 at Jackson Hills Assisted Living, information provided about how to operate the facility within substantial compliance. Pre licensing is complete and this facility has no deficiencies. An exit interview was conducted with James Jordan, Nataliya Regan, and Cheryl Boehme. A copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant have questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Sep 10, 2024

The state marks this report as 5 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 70 Census (if any clients in care): 43 COMP II Participants: James Jordan Interview Method: Telephone interview On July 8, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staffing, training, medications 3. Bedridden; fire inspection to be updated to reflect these rooms 4. Pre Licensing inpsection readinessthe state’s words, verbatim · CDSS document, Jul 8, 2024