075601160-5-19-2023-15-AS-KHOS-CSBJDX-20230530065816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 05/19/2023
Date Signed: 05/19/2023 04:00:54 PM

Unsubstantiated

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
01/11/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220111112239

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: 4	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Stewart Morris, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Administrator handled resident roughly
Administrator yells at resident

INVESTIGATION FINDINGS:

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On 05/19/23 at 3:50PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Administrator handled resident roughly
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed residents (R2, R3). Residents confirmed with LPA that staff (administrator, S1) never handled them roughly. R2 and R3 stated staff always treat them with respect and assist them with their activities of daily living (ADLs) feed them 3 meals a day plus snacks, assist them with their doctors' appointments, go on outings and shopping. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220111112239

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: 05/19/2023

NARRATIVE

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Allegation: Administrator handled resident roughly
Investigation Finding: Unsubstantiated
Continuation:
Witness (W1) confirmed with LPA that she never witnessed staff yell or hit any resident (R1, R2, R3) at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that the administrator handled resident roughly is unsubstantiated.

Allegation: Administrator yells at resident
Investigation Finding: Unsubstantiated
During investigation, administrator (ADM) stated that resident (R1) has muscular dystrophy which affected her hearing muscles requiring him to get close to R1 and speak louder so she can hear him. R1 passed away under hospice care on 01/20/22. Staff (ADM, S1) denied yelling or hitting any resident at the facility. Residents (R2, R3) confirmed with LPA that staff do not yell or scream at them. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that administrator yells at resident is unsubstantiated.

Exit interview conducted and a copy of the report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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