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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 04/18/2023
Date Signed: 04/18/2023 04:36:40 PM


Document Has Been Signed on 04/18/2023 04:36 PM - 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: 35DATE:
04/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator Amy JeffersTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Amy Jeffers.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office on 03/25/2023. The report described an alleged personal rights incident involving Resident #1 (R1) and Staff #1 (S1) on or about 03/18/2023, as witnessed by Staff #2 (S2). Per the SOC341, S2 first reported their concerns to a supervisor on 03/24/2023, at which point licensee immediately suspended S1’s employment pending internal investigation.

During today’s visit, LPA briefly toured the facility and performed a welfare check on R1. LPA also collected pertinent records and interviewed facility management.

Based on interviews and records available today: upon learning of the alleged incident, licensee timely cross-reported it to R1’s responsible party, R1’s physician, the San Diego County Long Term Care Ombudsman (LTCOP), the San Diego Police Department (SDPD), and CCLD. SDPD officer(s) visited the facility on 03/25/2023 to interview R1 and S2 but determined there was insufficient evidence/cause to open a criminal case. To date, LTCOP has not contacted the licensee or visited the facility regarding the incident.

Licensee completed their own internal investigation on 03/28/2023, which included interviewing S1 and S2; it concluded that S1 did not violate R1’s personal rights. Licensee reinstated S1's employment on 03/29/2023.

LPA was unable to directly interview S1 and S2 during today's visit, because both persons were not at work at the time.

No deficiencies were identified or cited during today's visit.

An exit interview was conducted with Jeffers, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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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