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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:45:29 PM


Document Has Been Signed on 03/29/2023 02:45 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, 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:
03/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Stewart Morris, AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/29/2023 at 11:45 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived conducted Case Management visit while at the facility for complaint #15-AS-20220106085047 and #15-AS-20230329120234. LPAs met with Administrator, Stewart Morris.

At 12:05 PM, LPA observed R2 buckled in the wheel chair. Administrator stated that resident was admitted to the facility on 3/1/2023 with the wheelchair. LPA did not observe a doctor's order on file. At 2:25 PM, Administrator had R2 demonstrate to LPAs if R2 is able to unbuckle independently. However, R2 was unable to unbuckle the wheelchair belt.

The following deficiency observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
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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Document Has Been Signed on 03/29/2023 02:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: JEFFERSON CARE HOME
FACILITY NUMBER: 075601160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited

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87608(a)(1) POSTURAL SUPPORTS
(1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position....

This requirement is not met as evidenced by:
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By POC date, Administrator agrees to submit an exception request and include physician's report, Care Plan, and doctor's order to CCLD
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Based on observation, Licensee did not comply with the regulation cited above. LPA observed a belt on R2's wheel chair strapped around R2's waist. R2 was not able to remove buckle independently which poses a potential personal rights to persons in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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