075601160-10-29-2021-15-AS-KHOS-C8DJAR-20211102065308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 10/29/2021
Date Signed: 10/29/2021 04:22:56 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
10/22/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20211022145432

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:	10/29/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Stewart Morris, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff hits resident
Staff yells at residents
Staff is incompetent with providing proper care for residents
Facility failed to arrange a follow-up appointment for residen

INVESTIGATION FINDINGS:

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On 10/29/21 at 2:30PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced complaint investigation and delivered the findings with administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Staff hits resident
Investigation Finding: Unsubstantiated
LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff never hit them. LPA observed R1, R2 and R3 to be well groomed, clean and relaxed in their environment. Witness (W1) also confirmed with LPA that staff never hit any resident at the facility.

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: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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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Control Number 15-AS-20211022145432

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: 10/29/2021

NARRATIVE

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Allegation: Staff yells at resident
Investigation Finding: Unsubstantiated
LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff never yells at them. Witness (W1) also confirmed with LPA that staff never yells at residents.

Allegation: Staff is incompetent with providing proper care for residents
Investigation Finding: Unsubstantiated
LPA interviewed residents (R1, R2 & R3) during visit. They confirmed with LPA that staff take good care of them such as assist them with activities of daily living (ADLs), feed them 3 meals a day plus snacks, assist them with their doctors' appointments, go on outings and shopping. R1, R2 and R3 told LPA that they feel safe living at the facility and treat staff as family since they have lived at the facility for more than 8 years.

Allegation: Facility failed to arrange a follow-up appointment for resident
Investigation Finding: Unsubstantiated
ADM told LPA that R1 broke her right thumb on 09/26/21 when she had an unwitnessed fall in her bedroom around 7PM. ADM called 911 but R1 refused to go with the paramedics. The next morning (09/27/21) ADM took R1 to the hospital to get her right thumb evaluated and treated. R1 was treated with a cast on her thumb and released back to the facility the same day. LPA observed R1 able to move her right elbow and thumb without any noticeable signs of pain or discomfort during visit. ADM told LPA he has been trying to get R1's follow-up doctor's appointment to no avail. ADM stated the county told him that R1's follow up appointment is not available for another 7 weeks. He also never got any response from R1's Medi-Cal agency. He told LPA he will take R1 to the hospital ER on 10/30/21 to get R1's cast removed.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are unsubstantiated. No deficiencies cited. Exit Interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

LIC9099 (FAS) - (06/04)

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