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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:03:12 PM


Document Has Been Signed on 09/18/2024 04:03 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:JACOB HEALTH CARE CENTERFACILITY NUMBER:
374603180
ADMINISTRATOR:CRUZ, JOSEPHFACILITY TYPE:
740
ADDRESS:4075 54TH STREETTELEPHONE:
(619) 582-5168
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY:40CENSUS: 38DATE:
09/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator Jaqueline OrtegaTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and discussed the purpose of the visit with Administrator Joseph Cruz and Assistant Administrator Jaqueline Ortega. The facility was licensed for a capacity of forty (40) non-ambulatory residents, of which ten (10) residents could be bedridden. The facility was also approved a hospice waiver for five (5) residents.

The LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected resident bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. There were no pools, nor bodies of water on the premises. Per staff, no firearms, nor ammunition were kept at the facility. A carbon monoxide detector, and multiple fire extinguishers were observed throughout the facility.

Due to time constraints, a continuation visit on a subsequent day is necessary to complete the annual inspection. No deficiencies were cited on today's date.

An exit interview was conducted with Assistant Administrator Jaqueline Ortega, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058), were provided..
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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