Jacobs Home

Type of visit: Required - 1 Year

On 5/13/2026, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required using the CARE Inspection Tool. LPA met with Christine Poland/Licensee. LPA explained the purpose of today’s visit. The facility is licensed to serve (3) elderly adults ages 60 and above. Approved for (2) ambulatory residents and (1) bedridden. Facility has an approved hospice waiver for (3). Currently the home has (2) clients, they are from South Central Los Angeles Regional Center. This home is a single-story home consisting of: (2) resident bedrooms, (1) Full bathroom, living room, kitchen with dining area, laundry room (located in the kitchen area), and an outdoor shaded patio area. LPA Iniguez toured the physical plant with an administrator. There were no bodies of water or obstructions on the premises. A total of (2) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident’s personal belongings was observed. Bathroom was found to be within Title 22 regulations and were operational. LPA inspected the carbon monoxide detectors combo were in operable condition. Evaluation Report Continues LIC 809-C LPA Iniguez observed the facility to be clean, sanitary, and appropriately furnished at the time of the visit. Storage areas for personal hygiene were observed. Sharps objects and cleaning agents were locked and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available at the property. All fire extinguishers were charged and were operable. A review of (2) resident records and (2) staff records were conducted. LPA Cross and Iniguez checked (2) Medication Administration Records (MAR) and no discrepancies were found. The first AID kit was checked. The last facility disaster drill was: 1/2026. LPA observed the facility's infection control practices. A copy of the surety bond will be email to LPA Iniguez. Facility annual fees were paid during the annual Inspection. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Christine Poland/Licensee.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

On 04/09/25, Licensing Program Analyst (LPA) Yolanda Rosser conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the yearly inspection. LPA met with Michelle Poland , DSP and the purpose of the visit was explained. Administrator was contacted and permission was granted to DSP to conduct facility tour and sign the report. The Facility is licensed to serve 2 ambulatory residents and 1 bedridden an approved hospice waiver for 3 residents. None of the residents are diagnosed with dementia and 2 residents are receiving home health services. This home is a single story home consisting of: (2) resident bedrooms, (1) Full bathroom, , living room, kitchen with dining area, laundry room (located in the kitchen area) and an outdoor shaded patio area. LPA toured the Resident bedrooms and observed the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 110 F - 115 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available and completely stocked as required. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There is seating and table area for the residents. Also, there is plenty of space for outside activities. There are no security bars or weapons on the premises. Detached garage is used for storage only. It contained extra supplies of paper towels, incontinence supplies, wheelchairs, cleaning supplies, extra toiletries. Exit interview was conducted and a copy of the report was provided to Michelle Poland.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Case Management - Annual Continuation

On 4/11/24, Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with staff Michelle Poland who assisted with that visit. Due to computer issues LPA was unable to leave citations with staff at time of visit . However LPA informed staff M. Poland that she woould return to complete citations. On today date LPA Day met with staff Michelle Poland and explained that the purpose of todays visit was to issue citations that were not assessed on 4/11/24 -On 4/11/24 at 2:55 PM LPA Day requested to see the Adminstrators Certificate and was informed it was not at the facility at time of visit. -On 4/11/2024 at 3:15 PM LPA Day observed that client #3 has full length bed rails on his bed. Staff was unsure if a doctors prescription had been obtain for the bedrails. An exit interview was conducted and a copy of Report and Appeal Rights provided..the state’s words, verbatim · CDSS document, Apr 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 876085(A) · Plan of correction due date: Apr 25, 2024

Postural Support Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.the state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee will remove full-length bed rails in room B or have residents reassess to determine the need for the full-bed rails. If it is determined the residents require full-bed rails the licensee will submit and exception request for resident. Due to LPA by POC date.4/25/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(A) · Plan of correction due date: Apr 25, 2024

Administrator Qualifications All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management andthe state’s words, verbatim · CDSS document, Apr 17, 2024

Plan of correction: Licensee will send proof of hours and fees paid to Sacramento to obtain re certifiation for her Administrator certificate by POC date 4/25/2024 Sparkle.day@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the year inspection. LPA met with Michelle Poland , DSP and the purpose of the visit was discussed. The Facility is licensed to serve 2 ambulatory residents and 1 bedridden an approved hospice waiver for 3 resident. None of the residents are diagnosed with dementia or receiving home health or hospice care services. This home is a single story home consisting of: (2) resident bedrooms, (1) Full bathroom, , living room, kitchen with dining area, laundry room (located in the kitchen area) and an outdoor shaded patio area. LPA toured the Resident bedrooms and observed the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 110 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Exit interview conductedthe state’s words, verbatim · CDSS document, Apr 11, 2024