374603180-1-31-2024-08-AS-JLOT-D2MN9C-20240220091539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:53:50 PM

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
01/26/2024 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20240126160237

FACILITY NAME:	JACOB HEALTH CARE CENTER		FACILITY NUMBER:	374603180
ADMINISTRATOR:	CRUZ, JOSEPH		FACILITY TYPE:	740
ADDRESS:	4075 54TH STREET		TELEPHONE:	(619) 582-5168
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92105
CAPACITY:	40	CENSUS: 33	DATE:	01/31/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Assistant Administrator Jacqueline Ortega		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Unlawful Eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to open and close an investigation regarding the above mentioned allegation. LPA was greeted by, identified herself to, and explained the purpose of the visit and the basic elements of the complaint with Assistant Administrator Jacqueline Ortega.

During today’s visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed residents and staff.

The Department’s investigation consisted of interviews with residents and staff and review of records. It was alleged that the licensee unlawfully evicted Resident 1 (R1). Review of records submitted to the Department and interviews with staff and residents revealed that facility management issued a 3-day eviction notice for R1 on 1/26/2024.
Continued on LIC9099-C page...

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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-20240126160237

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: 01/31/2024

NARRATIVE

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The facility provided R1 with a copy of the eviction notice and submitted a copy of the eviction notice to the Department on 1/26/2024. Review of records and interviews with residents and staff revealed that the licensee also issued a 3-day eviction notice for Resident 2 (R2) on 1/27/2024. The facility provided R2 with a hard copy of the eviction notice and submitted a copy to the Department on 1/27/2024. Interviews with facility management revealed that the facility did not seek Department approval for the 3-day eviction notices for either R1 or R2 prior to issuing the eviction notice. The Department denied both 3-day eviction notices for R1 and R2 on 1/29/2024. Neither R1 or R2 have been physically evicted from the facility at the time of this report. [Assistant Administrator was provided with an LIC811 Confidential Names list to identify R1 and R2].

The Department has investigated the above-mentioned allegation and based on interviews and records review, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC9099-D page.

An exit interview was conducted with Assistant Administrator Jacqueline Ortega and Administrator Joseph Cruz, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20240126160237

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: 01/31/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/16/2024 Section Cited CCR 87224(b)	1 2 3 4 5 6 7	87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit... This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide R1 and R2 with a written letter recinding the 3-day eviction notice and will receive vendor training regarding the eviction process. Administrator will submit a copy of the letters and proof of training to the Department by POC due date of 2/16/2024.
	8 9 10 11 12 13 14	Based on interviews and records review, the Licensee did not comply with the above regulation by not obtaining Department approval for the 3-day eviction notices prior to issuing written notices to R1 & R2. This poses a potential personal rights risk to 2 of 33 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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC9099 (FAS) - (06/04)

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