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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603244
Report Date: 04/11/2024
Date Signed: 04/16/2024 02:30:26 PM


Document Has Been Signed on 04/16/2024 02:30 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 ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



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: 3DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Michelle Poland, DSPTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the year inspection. LPA met with Michelle Poland , DSP and the purpose of the visit was discussed. The Facility is licensed to serve 2 ambulatory residents and 1 bedridden an approved hospice waiver for 3 resident. None of the residents are diagnosed with dementia or receiving home health or hospice care services.

This home is a single story home consisting of: (2) resident bedrooms, (1) Full bathroom, , living room, kitchen with dining area, laundry room (located in the kitchen area) and an outdoor shaded patio area. LPA toured the Resident bedrooms and observed the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 110 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

Exit interview conducted

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Sparkle DayTELEPHONE: (424) 544-1075
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
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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