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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604815
Report Date: 12/11/2025
Date Signed: 12/11/2025 06:06:03 PM

Document Has Been Signed on 12/11/2025 06:06 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
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: 31DATE:
12/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator Joseph CruzTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
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Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Joseph Cruz. LPA then met with RCFE Assistant Administrator Jacqueline Ortega, who arrived later.

According to the facility’s license, the facility has a maximum capacity of forty (40) residents, of whom all may be ambulatory or non-ambulatory, and up to ten (10) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of thirty-one (31) residents in care, of whom eighteen (18) were ambulatory, thirteen (13) were non-ambulatory, and none were bedridden. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter doors, and neither of these were present.

LPA reviewed records for multiple residents and multiple staff. LPA interviewed multiple residents and multiple staff. LPA, accompanied by Licensee’s staff, also toured the interior and exterior of the facility, and inspected all common areas and multiple resident rooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 74 F.

[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: JACOB HEALTH CARE CENTER
FACILITY NUMBER: 374604815
VISIT DATE: 12/11/2025
NARRATIVE
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[CONTINUED FROM LIC 809] Where tested, hot water temperature at taps accessible to residents were all compliant: Bedroom #2 Sink was 118 F, Bedroom #5 Sink was 116.4 F, Bedroom #17 Sink was 119.1 F, and Bedroom #22 Sink was 111.2 F. The Walk-In Refrigerator and Walk-In Freezer, which are used to preserve perishable food, were both complaint in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present and in good condition.

There were no hazardous objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No fireplaces, pools, or other similar bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility.

Smoke alarms, carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Fire/disaster drills were performed at required intervals. There were reserve supplies of Personal Protective Equipment (PPE) and staff had been trained on PPE within the last twelve (12) months. Licensee presented proof of current business liability insurance.

During review of five (5) sampled resident records, LPA observed, and manager interview confirmed: For two (2) of these residents [Resident #1 (R1) and Resident #2 (R2)], Licensee did not have documented proof that the resident had an annual physical (“annual routine visit”) with their own licensed medical professional, within the last twelve (12) months, as required. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] For four of these residents [R1 through Resident #4 (R4)], Licensee did not have documented proof of the occurrence of a care meeting/conference with the resident and appropriate individuals, “to review and revise the resident’s written record of care,” within the last twelve (12) months, as required. Resident #5 (R5) was the only resident in care receiving outside hospice care services. However, Licensee did not have documented proof that R1’s hospice agency provided “training specific to the current and ongoing needs of the individual resident receiving hospice care…before hospice care to the resident begins,” as required.

[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: JACOB HEALTH CARE CENTER
FACILITY NUMBER: 374604815
VISIT DATE: 12/11/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

During review of five (5) sampled staff records, LPA observed, and manager interview confirmed: Licensee did not have documented proof that two (2) direct care staff [Staff #1 (S1) and Staff #2 (S2)] completed at least twenty (20) hours of annual training, of which at least eight hours were on dementia care and at least four hours were on postural supports, restricted health conditions, and hospice care, as required.

Three (3) deficiencies was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding disaster drills, specifically the requirement to vary the type of disaster covered from one quarter to the next (refer to the LIC9102-TV page).

An exit interview was conducted with RCFE Assistant Administrator Jacqueline Ortega, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit. A copy of these same documents was also provided to Administrator Joseph Cruz.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/11/2025 06:06 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/11/2025 at 05:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER
FACILITY NUMBER: 374604815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that 2 of 5 sampled staff (S1 and S2) had completed 20 hours of training within the last year, of which 8 hours were required to be on dementia care and of which 4 hours were required to be on postural supports, restricted health conditions, and hospice care. This posed a potential health and personal rights risk to 31 of 31 residents [R1 through Resident #31 (31)] in care.
POC Due Date: 01/11/2026
Plan of Correction
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Licensee agreed to have S1 and S2 each finish 20 hours of annual training (ensuring at least 8 hours are on dementia care and at least 4 hours are on "postural supports, restricted health conditions, and hospice care"). Licensee agreed to clearly document the training, and to send proof of completion to LPA, by the POC due date.
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that 2 of 5 sampled residents (R1 and R2) had documentation of an annual routine visit with a licensed medical professional. This posed a potential health risk to persons in care.
POC Due Date: 01/11/2026
Plan of Correction
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Licensee agreed to coordinate with the responsible persons (RP) to ensure that R1 and R2 complete their annual routine physicals/medical visits. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/11/2025 06:06 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/11/2025 at 05:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER
FACILITY NUMBER: 374604815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, for 4 of 5 sampled residents (R1 through R4), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the written record of care. This posed a potential health risk to persons in care.
POC Due Date: 01/11/2026
Plan of Correction
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For R1 through R4 each, Licensee agreed to conduct a care conference with their responsible person (and home health/hospice personnel, as applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to faciliate such care conferences at least once every 12 months for each resident.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/11/2025 06:06 PM - It Cannot Be Edited


Created By: Dang Nguyen On 12/11/2025 at 05:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JACOB HEALTH CARE CENTER
FACILITY NUMBER: 374604815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)(B)
87633 Hospice Care of Terminally Ill Residents: “(b)(6)(B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins.” This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that the hospice agency trained 15 of 15 facility staff (S1 through Staff #15) on 1 of 1 hospice residents' (R5's) current and ongoing individual care needs. This posed a potential health risk to persons in care.
POC Due Date: 01/11/2026
Plan of Correction
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2
3
4
Licensee agreed to coordinate with the hospice agency for one of their nurses to lead an in-service training for staff, covering both the hospice care plan and the current and ongoing care needs of R5. Licensee agreed to E-mail the training sign-in sheet(s) to LPA, by the POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2025


LIC809 (FAS) - (06/04)
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