<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 10/15/2021
Date Signed: 10/15/2021 05:15:56 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
10/11/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20211011163104
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:
10/15/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Stewart Morris, AdministratorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Different adults are staying at the facility without clearance.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/15/2021 starting at 2:15pm, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation for the above allegation. LPAs met with Administrator, Steward Morris and explained the purpose of the visit. Regional Center of East Bay (RCEB), Synthia Hakola later arrived at 2:48pm to join LPAs.

Durring the complaint investigation, LPAs obtained information, collected documents, interviewed staff and witness. On 10/11/2021 W1 conducted a visit and met with S2 who is not finger print cleared. Interview with S1 on 10/15/2021 revealed S2 was left with a resident on 10/11/2021.

REPORT CONTINUES ON 9099C
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: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
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
Control Number 15-AS-20211011163104
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: 10/15/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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), are being cited on the attached LIC 9099D.

A repeat $250 and immediate $500 civil penalties are being assessed.

Exit interview conducted. Appeal rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
10/11/2021 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20211011163104

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:
10/15/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Stewart Morris, AdministratorTIME COMPLETED:
05:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Adults in facility are not wearing masks.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/15/2021 starting at 2:15pm, Licensing Program Analysts (LPAs) L. Francisco and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation for the above allegation. LPAs met with Administrator, Steward Morris and explained the purpose of the visit. Regional Center of East Bay (RCEB), Synthia Hakola later arrived at 2:48pm to join LPAs.

Durring the complaint investigation, LPAs obtained information, collected documents, interviewed staff and witness. On 10/15/2021 upon LPAs arrival, LPAs observed staff wearing mask.

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 and copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 15-AS-20211011163104
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: 10/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2021
Section Cited
CCR
87355(e)(1)
1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review.....1) Obtain a California clearance or a criminal record exemption as required by the Department…

This requirement was not met as evidence by:
1
2
3
4
5
6
7
By POC date administrator will review regulation and submit self certification letter that S2 is not to return to facility untill finger print cleared.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with regulation above. S1 confirmed S2 was left alone with a resident on 10/11/2021 which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 10/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4