374603180-10-30-2023-08-AS-SJAB-DAAV3W-20241022160526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:23:17 PM

Unfounded

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
10/26/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20231026152745

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:	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Joseph Cruz Administrator		TIME COMPLETED:	03:09 PM

ALLEGATION(S):

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Facility call light is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to commence a complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator Joseph Cruz

The Department’s investigation consisted of interviews and facility records review. It was alleged that the facility call light was in disrepair. LPA requested pertinent information for the month of October 2023. A review of records and interview with the Administrator revealed that the resident in question has not lived at the facility licensed by the Department. The facility the resident resided in is not within the Community Care Licensing Division's jurisdiction. As such, the Department has no jurisdiction to investigate. Therefore, the allegations are determined to be unfounded, which means that the allegations are false, could not have happened, and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (3/22) were left with the Wellness Director, whose signature on the form confirms receipt of these documents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy Domingo	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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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