374603180-1-11-2023-08-AS-DPOL-CNLVHJ-20230131152712

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 01/11/2023
Date Signed: 01/11/2023 11:14:33 AM

Substantiated

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
11/14/2022 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20221114104531

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: 38	DATE:	01/11/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Amy Jeffers, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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- Staff violated residents personal rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Carmen Lopez 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 Genesis Uribe, receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Amy Jeffers, Administrator.

The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, and LPA observation of the facility medication room. On November 14, 2022, it was alleged that staff violated resident’s personal rights.

A review of outside source records revealed that Staff #1 (S1) photographed resident’s personal information on their personal cell phone, uploaded and shared the information on their social media account.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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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Control Number 08-AS-20221114104531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 374603180
	VISIT DATE: 01/11/2023

NARRATIVE

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A review of facility records revealed that staff are provided a Non-Disclosure Agreement, Health Insurance Portability and Accountability Act (HIPAA) Compliance information, and Medical Information Confidentiality Agreement in the Employee Handbook. In addition to the Employee Handbook, staff are given a form, Prohibiting Staff from taking and/or Distributing Photographs and Recordings that Demean or Humiliate Residents which was signed by staff S1 on 4/12/2022. Lastly, employees are given a Loyalty, Confidentiality & Non-Solicitation Agreement that is initialed and signed by staff. During an interview with the Administrator, the Administrator recognized the photo of the staff person, S1, whose account disclosed the photo of the resident’s confidential information. Administrator also recognized a resident’s name that was disclosed and clearly visible within the photo. On November 15, 2022, LPA toured the facility and observed that staff personal belongings were kept in the area where the medication carts are located.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during staff interviews, records reviewed, and LPA observations, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Administrator Amy Jeffers. A copy of this report and LIC 811 along with Licensee/Appeal Rights (LIC9058 3/22) was provided to Administrator Jeffers at the conclusion of the visit. The signature below confirms the receipt of these documents.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20221114104531

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CENTER	FACILITY NUMBER: 374603180
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/13/2023 Section Cited CCR 87506(c)	1 2 3 4 5 6 7	87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. … this requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility will be conducting training with S1 on HIPAA, Personal Rights for RCFE, and Corrective Action will be taken by POC due date, 01/13/2023.
	8 9 10 11 12 13 14	Based on interviews and records review, staff did not protect residents’ confidential medication records. This posed a potential personal rights risk to 01 of 38 residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Rebecca Hedgecock	TELEPHONE: (619) 767-2329
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

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