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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601160
Report Date: 03/06/2025
Date Signed: 03/06/2025 12:44:33 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
02/25/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250225102154
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: 4DATE:
03/06/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dennis Ambat, TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee is not ensuring that the facility has adequate amount of food
Facility staff are not serving nutritious meals
Facility staff speak inappropriately to residents in care
INVESTIGATION FINDINGS:
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On 03/06/2025 at 09:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and Y. Brown arrived unannounced to conduct a complaint visit. LPA explained the purpose of the visit with Caregiver Dennis Ambat. Administrator Stew Morris was informed of the visit.

During the initial 10-day complaint visit LPAs toured the facility and interviewed staff, and residents. LPAs observed two refrigerators with minimal food in them. The produce that was observed in the kitchen was three lemons and two bags of lettuces. S2 stated that shopping is done every two weeks. In interviews with residents LPAs found that S1 frequently yells and curses in fromt of and at residents.

Based on LPAs interviews, 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), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
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 3
Control Number 15-AS-20250225102154
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: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2025
Section Cited
CCR
87468.1(a)(3)
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To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This requirement was not met as evidenced by:
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The facility agreees to have all staff read the regulations, obtain personal rights training from a CCLD approved vendor. Screaming and/or yelling shall cease immediately. Proof of completed training by those listed above to be submitted by POC date.
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Based on interviews, the licensee did not comply with the section cited above by yell and curse in front of and at residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250225102154
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: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
87555(b)(26)
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Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by:
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The facility agrees to purchase perishable food supply and submit photo of food and receipt. Proof of correction will be sent to CCLD by POC date.
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Based on observations, the licensee did not comply with the section cited above by not having two days of perishable foods in the refrigerators which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
03/13/2025
Section Cited
CCR
87555(a)
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The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council...This requirement was not met as evidenced by:
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The facility agrees to purchase a varity of food supply and submit photo of food and receipt. Proof of correction will be sent to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above by not having fresh fruit or vegetables for residents which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3