374603180-7-21-2022-08-AS-DNGN-CGJQTZ-20220721122759

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 07/21/2022
Date Signed: 07/21/2022 12:28:07 PM

Document Has Been Signed on 07/21/2022 12:28 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	JACOB HEALTH CARE CENTER		FACILITY NUMBER:	374603180
ADMINISTRATOR:	AMY JEFFERS		FACILITY TYPE:	740
ADDRESS:	4075 54TH STREET		TELEPHONE:	(619) 582-5168
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92105
CAPACITY:	40	CENSUS: 36	DATE:	07/21/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Administrator Amy Jeffers		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to follow up on an incident which licensee self-reported to the Community Care Licensing Division (CCLD) San Diego Regional Office (RO). LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Amy Jeffers. Licensee submitted to RO a LIC624 Unusual Incident Report and a SOC341 Report of Suspected Elder Abuse. According to the reports, on the afternoon of 01-28-2022, Resident #1 (R1) discovered their room burglarized and multiple jewelry items were missing. Facility video surveillance showed Staff #1 (S1) was the only person to enter the room while R1 was away. [See LIC811 Confidential Names List for identification of R1 and S1]. S1 denied stealing but was soon placed on administrative leave. The administrator notified the San Diego Police Department (SDPD), the San Diego County Long Term Care Ombudsman, and CCLD. After further review, Licensee arranged a meeting with S1 on 02-10-2022 to terminate their employment. SDPD personnel visited the facility that same day, interviewing and then arresting S1. CCLD’s investigation consisted of interviewing R1, the facility administrator, and the assigned police detective, and consulting with the San Diego County District Attorney’s office. Pertinent law enforcement reports, employment records, and facility video surveillance were also reviewed. Timestamped footage revealed that on 01-28-2022, R1 left their room at 3:17 PM. S1 passed them in the hallway, then entered R1’s room for 1 minute, 29 seconds. (When SDPD showed S1 screen captures from the surveillance video, S1 positively identified themselves in the video.) No other person entered or left the room. S1 returned to their room at 3:37 PM, then exited two minutes later, walking fast and “in obvious distress, with…hand over…mouth” (according to the police detective’s written synopsis of the footage), to hail down another staff for help. [CONTINUED ON LIC 809-C, 1 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER	FACILITY NUMBER: 374603180
	VISIT DATE: 07/21/2022

NARRATIVE

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[CONTINUED FROM LIC 809]

According to the facility administrator, who soon met with R1 in their bedroom, R1’s roommate was not present at the time, there were empty jewelry boxes inside R1’s dresser drawers, and there was no sign of forced entry via the one window inside the room (something the police detective corroborated during their own inspection). The room was thoroughly searched, but there was no sign of the missing jewelry. S1 was working as a caregiver on this day, but abruptly left work following the incident, citing a personal emergency.

R1 told SDPD that “no less than 14 items of jewelry” were stolen. S1’s name was checked against a law enforcement database of pawned items, leading police to a pawn shop located 1.7 miles from the facility, where they were able to locate and photograph 9 items which S1 had pawned, of which 4 were pawned on or after 01-28-2022. Of these 4 items, R1 was able to positively identify one as their property: it was a gold bracelet pawned on 02-02-2022 for $550. Although police were not able to locate R1’s other 13 jewelry pieces, they officially concluded that those items combined were worth at least “$1,000 fair market value.” Facility records established R1 as a reliable historian with no cognitive or psychotic impairment; their testimony remained credible and consistent across their three interviews with licensee, SDPD, and CCLD, respectively. Although S1 never confessed to the crime, they impaired their credibility. S1 told police they have never pawned an item in their life, yet database records showed they pawned 42 items totaling $30,000 since 2017. When confronted with photos of items they recently pawned, S1 changed their story and claimed the pawned items belonged to them.

On 02-10-2022, SDPD arrested S1 on two felonies: “459 – PC – Burglary (Residential) (F)” and “368(D) – PC – Theft of Elder/Dependent Adult (Larceny Over $950) (F).” The San Diego County District Attorney’s Office reviewed the case, determining there was sufficient evidence to prosecute S1 before a “felony jury trial.” A court judge also approved R1’s restraining order against S1, leading up to the trial.

[CONTINUED ON LIC 809-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/21/2022 12:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER	FACILITY NUMBER: 374603180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2022 Section Cited	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: …(25) To protection of their property from theft…” This requirement was not met, as evidenced by:
	8 9 10 11 12 13 14	Based on records and interviews, licensee’s employee (S1) stole property which belonged to a resident (R1) under licensee’s supervision. This posed an immediate personal rights risk to 1 of 39 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER	FACILITY NUMBER: 374603180
	VISIT DATE: 07/21/2022

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[CONTINUED FROM LIC 809-C, 1 of 2]

Licensee conducted a background check on S1 prior to their employment (revealing no criminal history), acted decisively following the incident, timely met reporting requirements, and fully cooperated with CCLD's own investigation. Nonetheless, based on records and interviews, a preponderance of evidence exists to show that S1 stole the private property of R1. Therefore, one deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with licensee. An exit interview was conducted with Jeffers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 01/16) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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