<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603244
Report Date: 04/17/2024
Date Signed: 04/17/2024 04:04:04 PM

Document Has Been Signed on 04/17/2024 04:04 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:JACOBS HOME INCFACILITY NUMBER:
198603244
ADMINISTRATOR/
DIRECTOR:		POLAND, CHRISTINEFACILITY TYPE:
740
ADDRESS:1629 W 84TH PLTELEPHONE:
(323) 531-2050
CITY:LOS ANGELESSTATE: CAZIP CODE:
90047
CAPACITY: 3CENSUS: 3DATE:
04/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Michelle PolandTIME VISIT/
INSPECTION COMPLETED:
04:03 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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..

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/17/2024 04:04 PM - It Cannot Be Edited


Created By: Sparkle Day On 04/17/2024 at 03:07 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: JACOBS HOME INC
FACILITY NUMBER: 198603244

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
CCR
876085(A)

1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
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
Type B
04/25/2024
Section Cited
CCR
87405(A)

1
2
3
4
5
6
7
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 and
1
2
3
4
5
6
7
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
8
9
10
11
12
13
14
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Sparkle Day
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2