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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 05/12/2022
Date Signed: 05/12/2022 11:03:25 AM

Document Has Been Signed on 05/12/2022 11:03 AM - 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:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Evan Park, CaregiverTIME COMPLETED:
11:12 AM
NARRATIVE
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On 05/12/2022 at 08:45 AM Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to conduct a Case Management. LPA met with Caregiver Evan Park (S1). The staff called the Licensee Stewart Morris and informed him of the visit. Stewart notified the LPA and the staff that he would not be able to make it to the facility. The Licensee dedicated S1 to sign off on the report.

LPA via phone explained the reason for the visit to Stewart. The LPA is following up about the claims that Stewart had made about having updated documentation regarding the control of property. As stated in the case management report dated 04/27/2022 “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.”

The Licensee was given till 05/06/2022 to provide CCLD and RCEB with these documents. As of 5/12/2022 both RCEB and CCLD have not received any of the requested documentation.

The Licensee made a false claim, that he had documentation that contradicted the document that was submitted to CCLD.

The deficiency was observed (see LIC809-D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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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Document Has Been Signed on 05/12/2022 11:03 AM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 05/12/2022 at 09:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JEFFERSON CARE HOME
FACILITY NUMBER: 075601160

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2022
Section Cited
CCR
87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement was not met as evidence by:
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Administrator needs to submit clear documentation about status of property by POC date.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above: By claiming that they would submit documentation that proves they still have control of property.
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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 Humpal
LICENSING EVALUATOR NAME:Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022


LIC809 (FAS) - (06/04)
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