Jacob Health Care Center

Type of visit: Required - 1 Year

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] [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] [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.the state’s words, verbatim · CDSS document, Dec 11, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Joseph Cruz. LPA also met with Assistant Administrator Jacqueline Ortega, who arrived later. Today's visit was in response to licensee’s self-reported deaths of Resident #1 (R1), which was received at the CCLD San Diego Regional Office (RO) on 07/04/2025, and Resident #2 (R2), which was received at the RO on 07/18/2025. [See LIC 811 Confidential Names List for a description of select person identifiers used]. Per the written death reports: R1 passed away at the hospital on 07/03/2025, and R2 passed away at the facility on 07/17/2025. During today’s visit, LPA performed a brief facility tour and welfare check on remaining residents, finding no immediate safety concerns. LPA also collected copies of and reviewed pertinent records and interviewed relevant staff. No deficiencies were observed or cited during today’s visit. An exit interview was conducted with Assistant Administrator Jacqueline Ortega, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit. An electronic set of these documents was also E-mailed to Administrator Joseph Cruz.the state’s words, verbatim · CDSS document, Jul 21, 2025

Type of visit: Collateral

Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Collateral visit. The LPA introduced himself and disclosed the purpose of the visit to Medication Technician Thelma Pajarit. Administrator Joseph Cruz and Assistant Administrator Jacqueline Ortega arrived during the visit and assisted the LPA. During the visit, the LPA conducted interviews and requested records. An exit interview was conducted with Assistant Administrator Jacqueline Ortega, to whom a copy of this report, and Licensee Right (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Apr 2, 2025

Type of visit: Prelicensing

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.the state’s words, verbatim · CDSS document, Dec 17, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for the Elderly (RCFE) Application Type: Change in Ownership (CHOW) Capacity: 40 Census (if any clients in care): 36 COMP II Participants: Toby Tilford, Applicant Joseph Cruz, Administrator Interview Method: Virtual interview (Microsoft Teams) On October 30, 2024 at 9:30 AM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program. 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview with Administrator. Report sent via email and informed to return sign copy to CAB by end of business day today.the state’s words, verbatim · CDSS document, Oct 30, 2024