075601160-10-1-2021-15-AS-KHOS-C7QHS6-20211012062633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 10/01/2021
Date Signed: 10/01/2021 03:50:31 PM

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
09/29/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210929100712

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:	10/01/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	MORRIS, STEWART		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Illegal eviction

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/1/2021 at around 11:35 AM, Licensing Program Analyst (LPA) L. Ibo and RCEB Quality Assurance ( Q.A) Synthia Hakola conducted a joint visit at the facility to conduct investigation for the above allegation. LPA & QA met with Administrator Stewart Morris. LPA informed Administrator the purpose of the visit.

During the course of investigation, LPA obtained information, collected documents and interviewed staff and residents. According to Administrator the facility is not closing, based on LPA interview with a resident, R2 is moving out voluntarily. Two other residents moved out 10/1/2021 per Administrator. LPA observed during the visit that family of R5 & R6 moved out residents’ belongings.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, copy of this report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2021

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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