374603180-5-3-2023-08-AS-DNGN-CRGT59-20230503142511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:25:22 PM

Document Has Been Signed on 05/03/2023 02:25 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 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: 36	DATE:	05/03/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator Amy Jeffers		TIME COMPLETED:	02:30 PM

NARRATIVE

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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 Receptionist Genesis Uribe. LPA then met with Administrator Amy Jeffers, who arrived later during the visit.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (and was received on 05/01/2023). According to the LIC624: Resident #1 (R1), who was their own responsible party and able to safely leave the facility unassisted, departed the facility on 04/26/2023. [See LIC 811 Confidential Names List for a description of R1.] On 04/28/2023, since R1 had not returned to the facility or answered their cell phone since leaving, licensee notified R1's case manager, physician and local police.

During today’s site visit, LPA briefly toured the facility, collected pertinent records, and interviewed relevant staff. According to staff interview: On 05/01/2023, San Diego Police Department (SDPD) made successful phone contact with a relative of R1, who confirmed to police that R1 was unharmed and staying with them. SDPD thus closed their missing-persons case. As of CCLD’s 05/03/2023 visit, R1 had not yet returned to the facility.

Per R1’s LIC602 Physicians Report (dated 01/08/2023), R1 was not diagnosed with cognitive impairment. Their doctor determined that R1 was “able to communicate needs,” “able to follow instructions,” and “able to manage cash resources,” and wrote that R1 was not “confused/disoriented” and did not have “wandering” or “sundowning” behaviors. Per the LIC603 Pre-Placement Appraisal (dated January 2023) which licensee authored: R1 used a wheelchair following their pelvic fracture, but was also “able to transfer and mobilize independently” and was “alert and oriented times 4.”

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/03/2023

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[CONTINUED FROM LIC 809]

Interview of staff revealed: a) R1 had come and gone from the facility on past dates without any safety problem or difficulty; and b) licensee timely met reporting requirements following the incident.

No citation deficiencies were issued during today’s visit. However, one (1) Technical Violation was issued regarding 87507 Admissions Agreements (from Title 22, Division 6, Chapter 8 of the California Code of Regulations).

An exit interview was conducted with Jeffers, to whom a copy of this report, the LIC9102TV, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023

LIC809 (FAS) - (06/04)

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