374603180-8-6-2026-08-AS-JROO-DXAPLU-20260825112518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603180
Report Date: 08/06/2026
Date Signed: 08/06/2026 02:23:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/01/2023 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 08-AS-20231201151418

FACILITY NAME:	JACOB HEALTH CARE CENTER		FACILITY NUMBER:	374603180
ADMINISTRATOR:	AMY JEFFERS		FACILITY TYPE:	740
ADDRESS:	4075 54TH STREET		TELEPHONE:	(619) 582-5168
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92105
CAPACITY:	0	CENSUS:	DATE:	08/06/2026
		UNANNOUNCED	TIME BEGAN:	02:16 PM
MET WITH:			TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Licensee did not treat for pest
Facility did not have hot water
Staff did not assist resident with medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) J. Clancy-Czuleger sent this report to the former licensee at their last known mailing address via USPS-certified mail and via email to deliver the investigation findings for the above allegations. The facility ceased operations on or about 12/31/2024.

During the course of the investigation, The Department conducted interviews with 7 staff, 3 residents. The department collected and reviewed the following documents: Orkin pest services receipts

On the allegation: Licensee did not treat for pest
Based on interviews with LPA Sabel Martinez staff revealed that the facility has been treating the building for pests. Staff interviewed stated that before management get the building sprayed, they would see cockroaches, but they have not seen them since the building was sprayed. The facility had receipts from the contracted company showing that Orkin came and sprayed the facility in September and November.
Continued on LIC 9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20231201151418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 374603180
	VISIT DATE: 08/06/2026

NARRATIVE

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...Continued from LIC 9099

On the allegation: Facility did not have hot water

Based on interviews with LPA Sabel Martinez, staff stated they were aware of a resident’s concern about the water temperature in the room being too cold. Staff stated that they were checking the sink in that room regularly and found that the water temperature was within the licensing approved range. Other resident that were interviewed stated that they always had hat water in the mornings and did not notice any fluctuation of the water temperature.

On the allegation: Staff did not assist resident with medication

Based on interviews with LPA Sabel Martinez, Staff #2 (S2) stated that the resident had a recent medication change and would refuse on occasion. S2 stated that the residents’ doctor had recently passed away and the resident was under new medical care, which resulted in changes to the residents’ medications. The facility used MARs and staff would document refusals and medication given late. Multiple staff stated that the medication protocol was to reoffer the resident’s medication within a two-hour window.

Based on staff interviews, outside source interviews, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. . A copy of this report, along with Licensee/Appeal Rights (LIC 9058), was mailed via USPS Certified Mail to the former licensee’s mailing address on file.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

LIC9099 (FAS) - (06/04)

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