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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 10/05/2021
Date Signed: 10/05/2021 11:25:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JEFFERSON CARE HOMEFACILITY NUMBER:
075601160
ADMINISTRATOR:MORRIS, STEWARTFACILITY TYPE:
740
ADDRESS:1034 STIMEL DRIVETELEPHONE:
(925) 685-0275
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY:6CENSUS: 3DATE:
10/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Stewart Morris TIME COMPLETED:
11:40 AM
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On 10/5/2021 at 11:00AM Licensing Program Analyst ( LPA ) L. Ibo conducted an unannounced follow up case management visit , LPA met with Administrator Stewart Morris. There were 2 residents at the facility during the visit, there are at least 7 days non-perishable and 2 days perishable food supplies. Per Administrator he will keep calling staffing agency for additional staffing this week. Per Administrator additional staffing will be at the facility starting 10/9/2021. LPA requested for an updated LIC500 to reflect staffing schedule.

No citation noted during the visit, copy of this reported provided to Administrator.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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