198320100-4-14-2026-11-AS-EMAZ-DU9VQE-20260520163813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320100
Report Date: 04/14/2026
Date Signed: 04/14/2026 03:58:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2026 and conducted by Evaluator Alfonso Iniguez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260410143313

FACILITY NAME:	JACOBS ARF		FACILITY NUMBER:	198320100
ADMINISTRATOR:	JACOBS, ASHLEY		FACILITY TYPE:	735
ADDRESS:	13704 ARDATH AVENUE		TELEPHONE:	(850) 621-2309
CITY:	GARDENA	STATE: CA	ZIP CODE:	90249
CAPACITY:	4	CENSUS: 2	DATE:	04/14/2026
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Danelle Jacobs /Facility Administrator.		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff do not ensure facility is clean and sanitary
Staff do not ensure resident's bed is in good repair

INVESTIGATION FINDINGS:

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On 4/14/2026, at approximately 12:00 PM, LPA Alfonso Iniguez conducted an unannounced initial complaint visit. LPA Iniguez met with Ashley Jacobs/Facility Administrator. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: the department conducted the following interviews: Administrator interview, (A#1), Clients Interviews (C#1-C#2), and Staff interview (S#1). The department gathered the following documents: copy of personnel schedule dated 4/14/26, copy of resident roster dated:4/14/26, and a health and safety check of the facility.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260410143313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JACOBS ARF	FACILITY NUMBER: 198320100
	VISIT DATE: 04/14/2026

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff do not ensure facility is clean and sanitary.

The details of the complaint alleged that staff does not ensure facility is clean and sanitary.

On April 14, 2026, at approximately 1:00 pm, the department conducted a health and safety check of the facility. During the inspection, the department observed the kitchen, dining room, bathrooms, and the rooms of clients (C#1) and (C#2). All observed areas were found to be clean, sanitary, and in compliance with health and safety standards.

On April 14, during an interview with the facility administrator (A#1), (A#1) stated that stated that the facility follows a daily cleaning schedule for all common areas. Furthermore, (A#1) noted that staff obtain permission from residents before entering and cleaning their rooms. When asked whether any reports or concerns regarding cleanliness had been received, (A#1) indicated that no such issues had been reported. Additionally, (A#1) stated that if they personally observed an area that was not clean, they would address it immediately.

On April 14, 2026, the Department attempted to contact (C#1) via telephone three times, at 12:00 p.m., 12:30 p.m., and 1:00 p.m. The Department was unable to establish contact with (C#1) during any of the attempts.

On April 14, 2026, during interviews with clients in care (C#2), (C#2) stated that they had not noticed any areas of the facility that were unclean or not being cleaned regularly. In addition, (C#2) further stated that they feel the facility is kept clean and sanitary daily.

On April 14, 2026, during interviews with facility staff (S#1), (S#1) stated that their responsibilities related to maintaining cleanliness in the facility include cleaning every day in the morning and at night, which they identified as part of their regular duties.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260410143313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JACOBS ARF	FACILITY NUMBER: 198320100
	VISIT DATE: 04/14/2026

NARRATIVE

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Additionally, (S#1) stated that they have not noticed any challenges or concerns with keeping any areas clean and sanitary, indicating that no further corrective steps have been necessary.

Allegation: Staff do not ensure resident's bed is in good repair

The details of the complaint alleged that staff do not ensure client’s bed are in good repair

On April 14, 2026, at approximately 1:00 p.m., during a health and safety check of the facility, the department observed that both clients in care (C#1 and C#2) had beds that were in good condition. The bed frames were not in disrepair, and the mattresses and bed sheets were clean and sanitary, indicating that the sleeping areas were properly maintained.

On April 14, during an interview with the facility administrator (A#1), (A#1) stated that before any client moves into the facility, staff ensure that all required furniture, including the resident’s bed, is present and in good repair. (A#1) explained that this is part of the facility’s standard move-in preparation process to confirm that beds are safe, functional, and appropriate for resident use. In addition, when asked whether there have been any recent reports, maintenance requests, or observations regarding damaged or broken resident beds, (A#1) stated that no reports have been made regarding the condition of either client’s bed. (A#1) stated that no concerns have been raised by residents or staff related to bed safety or repair needs.

On April 14, 2026, during an interview with client (C#2), (C#2) stated that their bed has been comfortable and in good condition, and they have not noticed any problems with it. In addition, when asked whether they had ever reported any issues with their bed and how staff responded, (C#2) stated that they have not had any problems at all and therefore have not needed to make any reports regarding their bed.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260410143313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JACOBS ARF	FACILITY NUMBER: 198320100
	VISIT DATE: 04/14/2026

NARRATIVE

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On April 14, 2026, during an interview with facility staff (S#1), (S#1) stated that if a resident’s bed is broken, they would report the issue to the licensee right away. (S#1) explained that this is the facility’s process for addressing problems with resident beds or other furniture in their rooms to ensure repairs are handled promptly. In addition, when asked whether they had observed any client beds that were damaged or in need of repair, (S#1) stated that they had not observed any such issues.

During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Ashley Jacobs /Facility Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC9099 (FAS) - (06/04)

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