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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320100
Report Date: 07/10/2026
Date Signed: 07/10/2026 12:17:24 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
07/02/2026 and conducted by Evaluator Lizeth Villegas
COMPLAINT CONTROL NUMBER: 11-AS-20260702134858
FACILITY NAME:JACOBS ARFFACILITY NUMBER:
198320100
ADMINISTRATOR:JACOBS, ASHLEYFACILITY TYPE:
735
ADDRESS:13704 ARDATH AVENUETELEPHONE:
(850) 621-2309
CITY:GARDENASTATE: CAZIP CODE:
90249
CAPACITY:4CENSUS: 2DATE:
07/10/2026
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Licnesee Ashey JacobsTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not safeguard the client's personal items.
INVESTIGATION FINDINGS:
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On 07/10/26 at 9:15 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with Licensee Ashley Jacobs (staff #1/ S1) as the purpose of today’s visit was explained.

The investigation consisted of the following: On 07/10/26 LPA Villegas obtained copies of the staff and client rosters, facility surety bond, and copies of the following documents for client #1-2 (C1-C2) Facesheets, admission agreement, consent forms, personal rights, Individual program plans (IPPs), and P&I ledgers. On 07/10/26 LPA conducted Interview with (S1), toured the facility, and conducted a P&I ledger review for client (C1-C2). On 07/10/26 LPA conducted a review of documents obtained.

The investigation revealed the following:
Allegation: Staff did not safeguard the client's personal items.
It is alleged that facility staff stole clients cash resources.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20260702134858
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: 07/10/2026
NARRATIVE
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On 07/10/26 LPA conducted Interview with (S1) regarding the allegation above. S1 denied the allegation above and stated that (S1) has not received any reports from clients nor staff that money has been misplaced or stolen from the facility. Per S1, if a report is made S1 would investigate and assist with locating the the missing money, report to Regional center, CCLD, conservator(s), families, and make a police report if applicable. On 07/10/26 LPA attempted to conduct interview with C1, however C1 did not wish to speak to LPA. On 07/10/26 LPA could not conduct interview with C2 as C2 was on an outing with their day program.
LPA conducted review of admission agreement for (C1) dated: 03/13/26, per admission agreement Licensee will handle client's cash resources. LPA Villegas and (S1) conducted P&I ledger review for C1-C2, LPA observed P&I ledger amounts to match the physical cash at the facility. On 07/10/26 LPA conducted a review of documents obtained, LPA observed facility surety bond active (Western Surety Company Bond #65039174 EXP: 07/01/28). On 07/10/26 LPA conducted a facility tour and observed clients bedrooms to be locked, per S1 clients have their own key to their bedrooms. There are copies of the bedroom keys that will only be used for an emergency.

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.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:

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

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2