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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:55:10 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
01/06/2022 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220106085047
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
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Stewart Morris, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not being properly trained
INVESTIGATION FINDINGS:
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On 3/29/23 at 10:40 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, interviewed staff and residents. It was alleged staff are not being properly trained. Based on record review on 3/29/23 at 11:20 AM, LPAs observed S2 did not receive the proper training requirements upon being hired in October of 2022.

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

Exit interview conducted. Appeal Rights and a copy of this report provided to Administrator.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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
01/06/2022 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20220106085047

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
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Stewart Morris, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
3
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5
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8
9
Uncleared adult providing care to residents
Uncleared adult in home not wearing a mask
INVESTIGATION FINDINGS:
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13
On 3/29/23 at 10:40 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct complaint investigation for the above allegations. LPAs met with Administrator, Stewart Morris and explained the purpose of the visit.

During the course of the investigation, LPA L. Francisco obtained information, reviewed records, collected documents, interviewed staff and residents. It was alleged uncleared adult providing care to residents and not wearing a mask. Based on record review and interview with staff and residents , LPAs observed staff listed on LIC 500 are fingerprint cleared. 3 of 3 residents denied observing other adults providing care to residents other than the fingerprint cleared staff.


REPORT CONTINUES ON 9099C
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20220106085047
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: 03/29/2023
NARRATIVE
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This agency has investigated the complaint alleging uncleared adult providing care to residents and uncleared adult in home not wearing a mask. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of this report provided to Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20220106085047
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: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited
CCR
87411(c)
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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
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By POC date, Administrator agrees to submit a training schedule for S2 or a copy of completed training in accordance to the regulation Title 22 and Health and Safety to CCLD
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This requirement is not met as evidenced by: Based on record review, LPAs observed S2 did not meet training requirements upon being hired in October of 2022 which poses a potential health and safety risk 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4