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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603244
Report Date: 04/25/2022
Date Signed: 05/06/2022 03:19:43 PM

Document Has Been Signed on 05/06/2022 03:19 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:JACOBS HOME INCFACILITY NUMBER:
198603244
ADMINISTRATOR:POLAND, CHRISTINEFACILITY TYPE:
740
ADDRESS:1629 W 84TH PLTELEPHONE:
(323) 531-2050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 3CENSUS: 1DATE:
04/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Christine PolandTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with Licensee Christine Poland and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. The facility is a Residential Care Facility for the Elderly. There is currently one (1) South Central Los Angeles Regional Center (SCLARC) resident in placement. The facility is licensed for two (2) ambulatory residents and one (1) bedridden resident. The facility has an approved hospice waiver for 3 residents. The facility's annual fees are current.

The following Domain will be observed and reviewed: Infection Control Practices "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections."

The facility is a single-family back house located in a residential neighborhood. Staff and LPA Bunker toured the facility which consisted of the following: Living room, dining area, kitchen, 2 bedrooms, 1 bathroom, laundry area in the kitchen, shaded area, indoor/outdoor activity areas, and a detached garage. The front and back yard landscape is in good condition at the time of the visit. See continued LIC809-C on page 2
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: JACOBS HOME INC
FACILITY NUMBER: 198603244
VISIT DATE: 04/25/2022
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Continued LIC809-C page 2

Documents are posted as mandated. Bedrooms contain the required furniture, Bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, comfort, and non-skid surface mats. The kitchen was observed for the ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are locked in the hallway closet, and records are current. Common areas were observed for the ability to safely serve the needs of the residents, including cleanliness, and clearness of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, hot water temperature measured at 110 degrees Fahrenheit within the normal limits (105-120F degrees), the fire extinguishers are fully charged, adequate linen supply, the facility telephones are working. The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were in compliance, the yard was free of debris hazards, and trash cans were covered. Staff was given training on dependent adult and elder abuse reporting. the facility conducted a fire drill on December 20, 2022.

There were no deficiencies cited.

Exit interview conducted.
SUPERVISORS NAME: Angela J Kendrick
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC809 (FAS) - (06/04)
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