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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 09/07/2022
Date Signed: 09/07/2022 12:06:38 PM


Document Has Been Signed on 09/07/2022 12:06 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: 34DATE:
09/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Amy Jaffers, and Assistant Administrator, Jacqueline OrtegaTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Sabel Martinez visited the facility to conduct an annual required licensing inspection. The LPA identified himself and disclosed the purpose of the visit to Assistant Administrator, Jacqueline Ortega. Administrator, Amy Jeffers, arrived during the visit.

During today's visit, the LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs posted at facility entrance with the facility’s visitor policy and signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; and an adequate supply of PPE. The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808.

No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator, Amy Jaffers, and Assistant Administrator, Jacqueline Ortega, to whom a copy of this report, along with the Licensee Rights (LIC 9058 FAS 01/16) were provided to.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2022
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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