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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701069
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:49:35 PM

Document Has Been Signed on 08/24/2022 03:49 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:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Shane StumpfTIME COMPLETED:
04:15 PM
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On 8/24/22 at 1:15pm Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Required 1 year annual inspection at Jazba Care LLC. LPA met with Licensee Shane Stumpf and together conducted a tour of the home and conducted file review for the resident in care.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident 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 3 interior cameras in the facility. LPA was able to observe no cameras had a view of a resident bedroom or bathroom utilized by a resident.

LPA measured the water temperature, temperature measured at 105 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.

LPA Gould reviewed three resident files and observed them to be complete and well organized. LPA reviewed two staff files and Licensee could not locate several staff documents including LIC 503 for both staff files. Licensee searched for items but could not locate. LPA and Licensee discussed organizational strategies for staff files and provided Licensee with LIC 311F indicating the documents required for the facility to maintain.

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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 08/24/2022 03:49 PM - It Cannot Be Edited


Created By: Kevin Gould On 08/24/2022 at 03:36 PM
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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JAZBA CARE LLC
FACILITY NUMBER: 342701069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of two staff files the licensee did not comply with the section cited above in 2 out of 2 staff files reviewed by LPA and could not locate several employee files including but not limited to LIC 503 health screening which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed several files being stored electronically but could not be accessed at the time of inspection.
POC Due Date: 08/31/2022
Plan of Correction
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Facility will provide LPA a written statement acknowledging that it is a requirement for all personnel files to be maintained at the facility and LPA must be able to inspect all documents. Facility will also provide LPA with documents he was unable to review at the time of inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022


LIC809 (FAS) - (06/04)
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