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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 03/06/2025
Date Signed: 03/06/2025 12:43:01 PM

Document Has Been Signed on 03/06/2025 12:43 PM - 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/
DIRECTOR:		MORRIS, STEWARTFACILITY TYPE:
740
ADDRESS:1034 STIMEL DRIVETELEPHONE:
(925) 685-0275
CITY:CONCORDSTATE: CAZIP CODE:
94518
CAPACITY: 6CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH: Dennis Ambat, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 03/06/2025 at 09:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger and Y. Brown arrived unannounced to conduct a Case Management. LPA met with caregiver Dennis Ambat. Administrator Stew Morris was informed of the visit.

While LPA J. Clancy-Czuleger conducted a complaint investigation (15-AS-20250210154802) on 2/20/2025, LPA was informed that the administrator had not been to the facility in over a month, the administrator did not provide assistance to staff during a power outage and did not give instructions on relocation, the facilities emergency disaster was not up to date, staff have not received training for emergency disasters, annual fee has not been paid.

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. A copy of this report and appeal rights provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/06/2025 at 10:56 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: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2025
Section Cited
CCR
1569.695(d)

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A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.
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The Facility agrees to fill out the updated emergency disaster plan. Proof of correction will be sent to CCLD by POC date
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This requirement was not met as evidenced by: Not having an updated emergency disaster plan at the facility.
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Type A
03/08/2025
Section Cited
HSC1569.695(b)

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A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement was not met as evidenced by:
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The facility agrees to conduct in-service training on staff responsibilities during a disaster drill. document and email CCLD a copy of the sign in sheet with topic of training date, time and name of trainer no later than the POC date.
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Staff not known what to do or where to go during a multi day power outage at the facility.
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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: 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


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 12:43 PM - It Cannot Be Edited


Created By: Jill Clancy-Czuleger On 03/06/2025 at 10:58 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: 03/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2025
Section Cited
CCR
1569.185((a)(1)

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An application fee adjusted by facility and capacity shall be charged by... After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license.This requirement was not met as evidenced by:
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Facility agrees to pay the outstanding annual fee. Proof of correction will be sent to CCLD by POC date.
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LPA conducted records check via LIS which revealed outstanding annual fees due to the department which poses a potential risk to the health and safety of residents 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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