075601160-10-15-2021-15-AS-KHOS-CRFPTH-20230502113559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 10/15/2021
Date Signed: 10/15/2021 05:06:10 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20211012134600

FACILITY NAME:	JEFFERSON CARE HOME		FACILITY NUMBER:	075601160
ADMINISTRATOR:	MORRIS, STEWART		FACILITY TYPE:	740
ADDRESS:	1034 STIMEL DRIVE		TELEPHONE:	(925) 685-0275
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 3	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Stewart Morris, Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Medications were left accessible to clients in care.
Staff does not meet training requirements
Building alteration

INVESTIGATION FINDINGS:

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On 10/15/2021 starting at 2:15pm, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation for the above allegations. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit. Regional Center of East Bay (RCEB), Synthia Hakola later arrived at 2:48pm to join LPAs.

Durring the complaint investigation, LPAs obtained information, collected documents, interviewed staff and witness.

Allegation: Medications were left accessible to clients in care.

During LPAs tour of facility, LPAs observed unlocked medication in staff's room. On 10/11/2021, W1 observed unlocked medication inside office drawer.

REPORT CONTINUES ON 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 15-AS-20211012134600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/15/2021

NARRATIVE

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Allegation: Staff does not meet training requirements

Based on interview with W1, S2 is administering medications to residents and attaching a post it note on Medication Administration Record (MAR) for S1 to initial. Facility was unable to provide proof of training for S2.

Allegation: Building alteration

On 10/15/2021 during LPAs tour of facility, LPAs observed a room was added in the living room. LPAs observed 1 of 3 residents is occupying the added bedroom. However, there is no building permit or approved fire inspection on file.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

An immediate $500 Civil Penalty is being assessed.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20211012134600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/16/2021 Section Cited CCR 87202(a)	1 2 3 4 5 6 7	87202 FIRE CLEARANCE (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services.... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC date, Administrator agrees to transfer resident from unapproved fire clearance room into the vacant room that is indicated on the floor plan approved by the Fire Department. Administrator will submit a photo and self-certification to CCL by 10/16/2021.
	8 9 10 11 12 13 14	Based on observation and record review, Licensee did not comply with the regulations cited above. LPAs observed additional bedroom is not cleared by Fire Department which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 10/16/2021 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees..	1 2 3 4 5 6 7	DEFICIENCY CLEARED DURING VISIT. In addition, Administrator will review regulations and conduct an in-service training with staff and submit a copy of training agenda to CCL 10/28/2021.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observation and interview, Licensee did not comply with the regulation cited above. On 10/11/21, W1 observed unlocked medication inside office drawer. LPAs observed unlocked medication in staff's room which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20211012134600

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 10/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/29/2021 Section Cited CCR 87305(a)	1 2 3 4 5 6 7	*This is an amended report from visit on 10/15/2021* 87305 ALTERATIONS TO EXISTING BUILDING... (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	*This is an amended report from visit on 10/15/2021* By POC date, Administrator agrees to obtain a permit, complete LIC 200 and floor plan, and submit a copy to CCL.
	8 9 10 11 12 13 14	Based on observation and record review, Licensee did not comply with the regulation above. LPA observed walls were added to the living room to be converted into a bedroom which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 12/30/2022 Section Cited CCR 87411(c)	1 2 3 4 5 6 7	*This is an amended report from visit on 10/15/2021* 87411(c) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69	1 2 3 4 5 6 7	*This is an amended report from visit on 10/15/2021* By POC date, Administrator agrees to review regulation and submit self-certification letter of understanding to CCLD.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the regulation cited above not meeting the training requirements for S2 which poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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