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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 06/02/2022
Date Signed: 06/07/2022 11:03:26 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/10/2022 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220510154943
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: 5DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Shane StumpfTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Other: Facility is not providing authorized representatives with requested documents regarding mother's care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Jazba Care LLC on 6/2/22 at 1:15pm to conclude the investigation of the above allegations and to deliver the findings. LPA met with Licensee and together discussed the investigation details.

Based on the interviews conducted and statements obtained during the investigation process, the allegations cannot be corroborated because the facility and department has received no documentation from individuals who have been designated as having power of attorney (POA) had not provided to the facility any documentation from a physician that resident has been incapacitated an can no longer make their own medical decisions. Therefore, the resident's POA and POA for medical decision making has not been triggered at the time of writing this report. The department has determined that the resident has retained the right to their own decision making and the facility cannot share the information without the approval of the resident.

Report continued on LIC 9099-C.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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 27-AS-20220510154943
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 342701069
VISIT DATE: 06/02/2022
NARRATIVE
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The Department has investigated the complaint alleging Other. Based on the investigative interviews, record reviews and other supportive evidence, the complaint is determined to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Complaint has been dismissed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the Licensee 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: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2