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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 09/21/2022
Date Signed: 09/22/2022 08:36:30 AM


Document Has Been Signed on 09/22/2022 08:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



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: 37DATE:
09/21/2022
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Amy Jeffers and Client Coordinator, Jacob EdmondsTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced collateral visit to the facility to conduct an interview. The LPA identified himself and disclosed the purpose of the visit to Client Coordinator, Jacob Edmonds. Administrator, Amy Jeffers, arrived during the visit.

During the visit, the LPA interviewed Resident #1 (R1)(See LIC811 Confidential Names). No deficiencies were observed during today's visit.

An exit interview was conducted with Administrator, Amy Jeffers, to whom a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided via electronic mail. An electronic mail read receipt confirms these documents were received by the administrator.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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