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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601946
Report Date: 10/24/2022
Date Signed: 10/24/2022 12:23:31 PM

Document Has Been Signed on 10/24/2022 12:23 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:JACOBS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
198601946
ADMINISTRATOR:DENELL JACOBSFACILITY TYPE:
735
ADDRESS:5153 S. VICTORIA AVENUETELEPHONE:
(310) 863-1554
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 4CENSUS: 3DATE:
10/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Denell Jacobs - AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA), Mario Leon, conducted an unannounced Annual required visit with a primary focus on infection control measures. LPA was met by Denell Jacobs, Administrator, and the purpose of today’s visit was explained. The facility is licensed to serve 4 developmentally disabled clients (aged 18-59).

The facility is a single-story structure located in a residential neighborhood. There are currently three (3) South Central Regional Center clients in placement. All 3 clients are ambulatory. A tour of the single-story facility includes three (3) clients’ bedrooms and one (1) staff room, two [2] bathrooms, living room, dining area, kitchen, indoor/outdoor activity areas, detached storage garage, and one (1) guest home.

All clients’ bedrooms have the required furniture for privacy, comfort. Bathrooms are clean. On 10/24/2022 hot water temperature tested at one-hundred and five (105) degrees farenheit, Kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. All storage areas for chemical compounds, cleaning solutions, toxins, knives or hazardous items are inaccessible to clients. LPA observed a weed killing spray left on top of a washing machine unit.

There are no bodies of water or firearm/ammunition on the premises. All client rooms were checked. Beds and bedding were in good condition, adequate lighting provided, storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were not found to be within Title 22 regulations, relating to missing a non-slip mat in bathroom number two (2), yet were clean. A comfortable temperature is maintained in the facility and the smoke detectors and carbon monoxide are in working order. One (1) fire extinguisher is fully charged. LPA observed the facility to be in need of straightening up, such as replacement of broken office desk in room number two (2).

See 809-C
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JACOBS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601946
VISIT DATE: 10/24/2022
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff and residents, sanitizing station ( Located in screening area). LPA observed staff were wearing face coverings, an isolation room and required postings throughout the facility. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA advised the Administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

During today’s visit there was (1) deficiency observed and two technical recommendations See: LIC 812 and LIC 9102

Exit interview held. A copy of the report was provided to Denell Jacobs.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2022 12:23 PM - It Cannot Be Edited


Created By: Mario Leon On 10/24/2022 at 12:13 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: JACOBS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 198601946

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Ulysses Coronel
LICENSING EVALUATOR NAME:Mario Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022


LIC809 (FAS) - (06/04)
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