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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 10/30/2024
Date Signed: 10/31/2024 08:23:50 AM

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
10/21/2024 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20241021164843
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: 36DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Director of Nursing May Asuncion and Assistant Administrator Jacqueline OrtegaTIME COMPLETED:
11:25 PM
ALLEGATION(S):
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Staff did not follow infection control procedures
Staff did not provide incontinence care
Staff did not assist resident with catheter care
Staff did not keep resident's bedroom clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced complaint investigation visit. The LPA identified himself and disclosed the purpose of the visit to Director of Nursing May Asuncion. Assistant Administrator Jacqueline Ortega arrived during the visit and assisted the LPA.

On October 21st, 2024, it was reported to the Department staff did not follow infection control procedures, staff did not assist a resident with incontinence care, staff did not assist resident with catheter care, and did not maintain a resident’s bedroom clean.

Review of records along with interviews of staff revealed the resident in question did not reside in the Assisted Living portion of the facility. This resident did reside in the skilled nursing facility adjacent and associated to Jacob Health Care Center. The skilled nursing component was not licensed through the California Department of Social Services and was regulated by a different agency.
(See LIC 9099C for continuation of report.)
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 08-AS-20241021164843
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: 10/30/2024
NARRATIVE
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Based on the information revealed during the visit, these allegations were deemed to be unfounded.

An exit interview was conducted with Assistant Administrator Ortega, to whom a copy of this report, and Licensee/Applicant Rights (LIC 9058), were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2