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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 08/18/2020
Date Signed: 08/18/2020 12:03:39 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/13/2020 and conducted by Evaluator Debbie Correia
COMPLAINT CONTROL NUMBER: 08-AS-20200813095638
FACILITY NAME:JACOB HEALTH CARE CENTERFACILITY NUMBER:
374603180
ADMINISTRATOR:AMY JEFFERSFACILITY TYPE:
740
ADDRESS:4075 54TH STREETTELEPHONE:
(619) 582-5168
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY:40CENSUS: 38DATE:
08/18/2020
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Administrator, Amy JeffersTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to properly assist resident while in care.
Resident was not properly dressed while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced virtual visit to deliver investigative findings on the above listed complaint allegation. LPA met with Administrator, Amy Jeffers via (FACETIME) to whom was explained the reason for the visit.

During today's visit, a record review revealed the alleged victim was residing in the Skilled Nursing section of the facility. The San Diego Regional Office (SDRO) Community Care Licensing (CCL) Division does not have jurisdiction over Skilled Nursing Facilities (SNF), therefore the above allegation is determined to be Unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. LPA Correia will cross-report to the California Department of Public Health.

An exit interview was conducted with Amy Jeffers, Administrator and a copy of this report and Licensee Appeal Rights (LIC 9058) have been given for facility records.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2020
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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