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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601160
Report Date: 03/20/2025
Date Signed: 03/20/2025 03:08:22 PM

Document Has Been Signed on 03/20/2025 03:08 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: 3DATE:
03/20/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Dennis Ambat, Caregiver TIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 03/20/2025 at 1:30 PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to conduct a Plan of Correction (POC) visit. LPAs met with caregiver Dennis Ambat and explained the purpose of the visit.

On 03/06/2025, LPA conducted a complaint investigation and case management visit in which deficiencies were cited. The POC due dates was 03/07/25, 03/08/25, and 03/13/25. Administrator failed to submit the POC by the due dates and this is why LPAs came to make a POC visit.

Deficiencies not cleared:
1569.695(d)= $100 X 12 = $1200.00
1569.695(b)= $100 X 12 = $1200.00
1569.185(a)(1)= $100 X 7 = $700.00
87468.1(a)(3)= $100 X 12 = $1200.00
87555(b)(26)= $100 X 7 = $700.00
87555(a)= $100 X 7 = $700.00
1569.695(2)= $100 X 13 = $1300.00

Civil Penalties in the total amount of $7000.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing daily civil penalties until deficiencies is corrected.

Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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