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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603180
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:03:56 PM


Document Has Been Signed on 09/18/2024 04:03 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:JACOB HEALTH CARE CENTERFACILITY NUMBER:
374603180
ADMINISTRATOR:CRUZ, JOSEPHFACILITY TYPE:
740
ADDRESS:4075 54TH STREETTELEPHONE:
(619) 582-5168
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY:40CENSUS: 38DATE:
09/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator Joseph Cruz, and Assistant Administrator Jaqueline OrtegaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Joseph Cruz, and Assistant Administrator Jaqueline Ortega.

Today's visit was in response to an LIC 624 Incident Report and SOC 341 Report of Suspected Abuse, which the facility self-submitted to the CCLD San Diego Regional Office (and were received on 9/16/2024). According to the LIC 624, Resident #1 (R1), reported to staff that Staff #1 (S1) had borrowed fifty ($50) form R1, and S1 had not returned the borrowed money.

During the visit, the LPA secured pertinent records, and conducted interviews. No immediate concerns, nor deficiencies were observed during the visit, but additional telephone calls, and visits may be necessary.

An exit interview was conducted with Ortega, to whom a copy of this report, LIC 811, and Licensee Rights (LIC 9058), were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/18/2024
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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