374603180-7-2-2024-08-AS-SJAB-D9FN78-20240925101217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 07/02/2024
Date Signed: 07/02/2024 02:13:34 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/13/2022 and conducted by Evaluator Tiffany Holmes

COMPLAINT CONTROL NUMBER: 08-AS-20220913154200

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: 37	DATE:	07/02/2024
		UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Joseph Cruz, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Neglect resulted in severe dehydration.
Facility staff withheld medication.
Facility is not meeting resident's care needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced complaint visit to deliver findings on a complaint investigation regarding the above-mentioned allegation. LPA identified herself and was granted entry by Joseph Cruz, Executive Director. LPA stated the purpose of the visit and reviewed the findings of the complaint

The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, it was alleged that neglect resulted in resident being severely dehydrated. Interviews revealed Resident 1 (R1) went to the hospital and was diagnosed with being dehyrdated. R1 drinks their liquids and at times needs reminders. A review of records revealed that R1s Physicians reports states that the resident is able to feed themselves. It does state that the resident needed reminders which the staff provided. Interviews revealed they have ice water and juice on the med carts and water stations around the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220913154200

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 374603180
	VISIT DATE: 07/02/2024

NARRATIVE

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It was alleged that facility staff withheld medication. Interviews revealed the staff did not withhold the medication from R1. R1 uses insulin and if their blood glucose level is too high they will not give it to them, if it is low then the staff will provide R1 with insulin medication. Interviews revealed that R1 was tested on September 12, 2022 and their blood level was high , so staff did not provide resident their medication because their blood level was too high. The facility staff called 911 and R1 was sent out due to their blood levels being high.

It was alleged that facility is not meeting resident's care needs. Interviews revealed the staff are meeting the residents needs by assisting them with their activities of daily living ADLs for those that need it. Interviews with residents revealed they have no complaints about the staff and them meeting their needs. Interviews revealed the staff are kind and work hard to assist them. Based on the Department’s investigation of the above-mentioned allegations are unsubstantiated.

The report was discussed and an exit interview was conducted with Joseph Cruz, Executive Director and a copy of this report along with Licensee/Appeal Rights (LIC9058 3/22) was provided at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany Holmes	TELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC9099 (FAS) - (06/04)

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