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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:34:41 PM

Substantiated


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
09/12/2022 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20220912150514
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:
10/19/2022
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Shane StumpfTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Medication: Staff is not following physician's orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/19/2022 at 8:50 am to deliver complaint findings, LPA met with Shane Stumpf and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility records. LPA Martinez reviewed resident 1 (R1) medication orders, medication list, and Medication Administration Record (MAR), and Centrally Stored Medication And Destruction Record (CSMDR). The facility CSMDR record logged Amlodipine 5MG was filled January 27, 2022 and no start date. LPA Martinez reviewed R1's April 2022 Medication list, which stated Amlodipine 5MG. LPA Martinez reviewed R1's May MAR, which stated Amlodipine 2.5 MG and the first part of the May Mar was not completed. Furthermore, there was no discontinuance order for the 5MG and no start order for the 2.5 MG in May of 2022. However, a September 9, 2022 medical doctor order states Amlodipine dosage was changed to 2.5 MG. In addition, facility email correspondence reports R1's Amlodipine dosage was changed to 2.5 MG in September of 2022.
Continued..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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 3
Control Number 27-AS-20220912150514
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: 10/19/2022
NARRATIVE
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Furthermore, MARs for June, August, and September did not include the Amlodipine medication. As a result the facility was not following R1's physician medication orders. Also, the July 2022 MAR is missing and it's is unknown if medication was provided to R1.

As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

An exit interview was conducted, and a copy of this report and appeals rights was given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220912150514
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2022
Section Cited
CCR
87465(4)
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87465(4)Incidental Medical and Dental Care:
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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The Administrator agrees to conduct Incidental Medical and Dental Care training for all staff by POC Date 11/15/2022. The Administrator agrees to email LPA Martinez training documents by 11/15/2022.
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The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: based on observation the facility did not follow R1's physician's medications orders. This posed a potential health and safety risk to R1.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3