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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 09/19/2024
Date Signed: 09/19/2024 03:57:12 PM


Document Has Been Signed on 09/19/2024 03:57 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:
09/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Assistant Administrator Jacqueline OrtegaTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Annual Continuation visit. The LPA introduced himself and discussed the purpose of the visit with Assistant Administrator Jacqueline Ortega. Administrator Joseph Cruz arrived during the visit and assisted the LPA.

During today's visit, the LPA toured the facility's perimeter, reviewed required postings, reviewed staff and resident files, and conducted several interviews. The LPA also observed the facility's signal system. 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 Jacqueline 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: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
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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