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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 11:03:58 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: DATE:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Evan Park, Caregiver TIME COMPLETED:
11:12 AM
NARRATIVE
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On 05/12/2022, during the course of another visit, Licensing Program Analyst (LPA) J. Clancy-Czuleger observed a pill bottle left out on the desk. LPA interviewed staff about the bottle and determined that it was empty. LPA then asked the staff to open any unlocked drawers in office/desk area. LPA then observed a bottle of pills left in an unlocked drawer.

REPEATED VIOLATION CIVIL PENALTY ASSESSMENT:
Medication bottle left accessible to residents 87465(h)(2) repeat violation from 10/15/2021

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted With Caregiver Evan Park. 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)
Page: 1 of 2
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 10:36 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 A
05/13/2022
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees..
This requirement is not met as evidenced by:
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DEFICIENCY CLEARED DURING VISIT.

In addition, Administrator will review regulations and conduct an in-service training with staff and submit a copy of training agenda to CCL 5/26/2022.
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Based on observation and interview, Licensee did not comply with the regulation cited above, LPAs observed unlocked medication inside office drawer, which poses an immediate health and safety risk to residents in care.
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A $1000 Civil Penalty is being assessed for Repeat Violation

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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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