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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603244
Report Date: 07/25/2023
Date Signed: 07/25/2023 05:11:00 PM

Document Has Been Signed on 07/25/2023 05:11 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 HOME INCFACILITY NUMBER:
198603244
ADMINISTRATOR:POLAND, CHRISTINEFACILITY TYPE:
740
ADDRESS:1629 W 84TH PLTELEPHONE:
(323) 531-2050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 3CENSUS: 2DATE:
07/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:27 PM
MET WITH:Michelle PolandTIME COMPLETED:
05:28 PM
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On 07/25/2023, Licensing Program Analyst (LPA) Antonine Richard conducted a Case Management visit to the facility above. For the purpose of following up on a confirmation of removal notification. LPA met with staff Michelle Poland and explained the reason for the visit.

A notification letter was generated to notify the licensee of an individual (CE) confirmation of removal. LPA spoke with Christine Poland who explained that (CE) was an employee they were trying to hire. The individual (CE) never worked at the facility.

During this visit, LPA obtained a copy of the staff schedule for June and July of 2023 from the Administrator, which confirm that (CE) is not working at the facility. The Department received information an individual (CE) should not be on site, and this has been verified during today’s visit.

No citations issued during today's visit.

Report reviewed and signed, exit interview conducted, and a copy of this report was provided
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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