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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 12:49:47 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
02/10/2025 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20250210154802
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, CaregiverTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee did not ensure the facility had power
INVESTIGATION FINDINGS:
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On 3/6/2025 at 9:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger and Y. Brown arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Caregiver Dennis Ambat. Administrator Stew Morris was informed of the visit.

On the allegation: Licensee did not ensure the facility had power. LPA interviewed staff, residents and witnesses about the loss of power in February 2025. LPA was informed that the facility was without power for over a week and because the licensee did not pay the bill. During this time no alternative power resource was provided during the outage.

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 2
Control Number 15-AS-20250210154802
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
03/07/2025
Section Cited
HSC
1569.695(2)
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Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following ... a short-term or long-term power failure. If the facility plans to shelter in place ... Shall have a plan and supplies available to provide alternative resources during an outage. This requirement was not met as evidenced by:
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The facility agrees to purchase an alternative resource for power for the facility to be used in short-term or long-term power failure. Proof of correction will be sent to CCLD by POC date
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Based on interviews, the licensee did not comply with the section cited above by not having a plan and supplies available to provide alternative resources during an outage which poses/posed an immediate 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)
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