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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701069
Report Date: 10/06/2021
Date Signed: 10/06/2021 02:26:07 PM

Document Has Been Signed on 10/06/2021 02:26 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JAZBA CARE LLCFACILITY NUMBER:
342701069
ADMINISTRATOR:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:9031 TUOLUMNE DRIVETELEPHONE:
(562) 506-8473
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
10/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licnesee, Shane StumpfTIME COMPLETED:
02:45 PM
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On 10/06/2021 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Jazba Care LLC for the purpose of conducting a pre-licensing inspection. LPA met with Licensee, Shane Stumpf and together conducted a tour of the home. The home is a single story home in a residential community. The home consists of 4 bedrooms, two bathrooms. Two of the bedrooms are shared. All beds equipped with required linen and furniture and appropriate lighting.

LPA and Administrator evaluated the physical plant to ensure the health and safety of future residents. Areas inspected are including but not limited to the kitchen, bedrooms, bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed all sharp objects and cleaning supplies are made inaccessible. Facility dining room has enough chairs and plate settings to meet the needs of the population. LPA observed three (3) interior cameras and none of the cameras has a visual of a resident bedroom or bathrooms. LPA observed 4 exterior cameras, no cameras have audio. LPA observed an alarm on the front door, garage, sliding back door and emergency exit in bedroom #3. licensee has also installed floor mats with a censor to alert staff if a resident is getting out of bed and may need assistance.

LPA measured the water temperature, temperature measured at 114 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. A Component 3 orientation has been scheduled for 10/12/21 at 1:00pm. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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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