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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701069
Report Date: 10/19/2022
Date Signed: 10/20/2022 11:19:34 AM

Document Has Been Signed on 10/20/2022 11:19 AM - 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: 5DATE:
10/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Shane StumpfTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit on 10/19/2022. LPA met with Shane Stumpf and explained the purpose of the visit.

The purpose of the visit today, is in response to learned Incidental Medical and Dental Care technical violations. LPA Martinez reviewed facility medication records and learned the facility did not fully complete Medication Administration Record (MAR), and Centrally Stored Medication And Destruction Record (CSMDR). As a result, the facility received technical assistance from LPA Martinez, and technical violations were given.

An exit interview conducted and a copy of this report and technical violation documents were 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
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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