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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:01:52 PM


Document Has Been Signed on 04/27/2022 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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:
04/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Licensee Stewart MorrisTIME COMPLETED:
03:10 PM
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On 04/27/2022 at 2:30 PM Licensing Program Analysts (LPA) J. Clancy-Czuleger and RCEB quality insurance specialist Synthia Hakola arrived unannounced to conduct a Case Management. LPA met with Stewart Morris, Licensee.


CCLD received a documentation that the facility was legally obligated to close and the property is to be sold. Stewart stated that the document that was being referred to was not the most up to date document and that there was no plan at this time the property was being sold.

Stewart said that he will get up dated documentation and send it to CCLD and to RECB by 5/6/2022 or additional information if that time line is not able to be met
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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