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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604815
Report Date: 12/17/2024
Date Signed: 12/18/2024 09:33:08 AM

Document Has Been Signed on 12/18/2024 09:33 AM - 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:
374604815
ADMINISTRATOR/
DIRECTOR:
CRUZ, JOSEPHFACILITY TYPE:
740
ADDRESS:4075 54TH STREETTELEPHONE:
(619) 582-5168
CITY:SAN DIEGOSTATE: CAZIP CODE:
92105
CAPACITY: 40CENSUS: DATE:
12/17/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Joseph Cruz and Assistant Administrator Jacqueline OrtegaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Pre-Licensing visit. The LPA introduced himself and disclosed the purpose of the visit to Administrator Joseph Cruz and Assistant Administrator Jacqueline Ortega.

The facility was in the Change of Ownership process and a fire clearance was conducted and received by the Department. The facility was approved for a capacity of forty (40) non-ambulatory residents, where ten (10) could be bedridden. The facility also had a hospice waiver approved for five (5) residents.

During the visit, the LPA toured the interior and exterior of the facility and inspected resident bedrooms. The bedrooms contained the required furnishings. Showers, toilets, and window screens were in good repair. There were no slip hazard and the walkways were observed to be free of obstructions. Water temperatures were within the require range. No pools, nor bodies of water were observed throughout the facility. Per staff, no firearms, nor ammunition were kept at the facility.

The LPA also observed the facility had a sufficient amount of food. Resident call buttons were tested at random, and centrally stored medications were observed to be locked and labeled.

A Component III was conducted with Cruz and Ortega to discuss continuing requirements and physical plant. At this time the facility is ready to be licensed pending management approval.

An exit interview was conducted with Cruz and Ortega, to whom a copy of this report and the Licensee/Applicant Rights (LIC9058), were provided via email. An email read receipt confirms the documents were received by Cruz and Ortega.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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