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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 03/29/2024
Date Signed: 03/29/2024 03:51:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/21/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240321114138
FACILITY NAME:JAZBA CARE TUOLUMNEFACILITY NUMBER:
342701069
ADMINISTRATOR:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:9031 TUOLUMNE DRIVETELEPHONE:
(562) 506-8473
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 6DATE:
03/29/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Shane StumpfTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff members worked at facility without criminal record association
Staff files are incomplete
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

When LPA Moleski arrived at the facility, one staff member was present (S1). In an interview, S1 said that S1 had been working at the facility since November or December 2023. LPA Moleski reviewed Guardian records and observed that S1 was associated to the facility as of 3/26/24, one day after LPA Moleski opened a separate complaint investigation regarding criminal record clearances at another facility owned and/or operated by Stumpf. S1 said S1 had been working six days a week at the facility since starting. S1 said S1 had been working with S2 for about a month.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
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 4
Control Number 27-AS-20240321114138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE TUOLUMNE
FACILITY NUMBER: 342701069
VISIT DATE: 03/29/2024
NARRATIVE
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S2 arrived during this visit. In an interview, S2 said S2 had been working at this facility since about mid-February. S2 said S1 had been working at this facility since before S2 started working here. LPA Moleski reviewed Guardian records and observed that S2 had been associated to this facility as of 3/27/24.

Stumpf said S1 started working at this facility around the end of last year. Stumpf said that S2 had been working at the facility for less than a month.

In an interview, a consultant who had been working for the licensee (S7) said multiple staff members worked at this facility without having appropriate criminal record associations.

LPA Moleski reviewed S2's file. S2 did not have a health screening on file, despite having worked more than seven days at this facility.

The department has determined the following as it relates to the allegations that staff members worked at this facility without criminal record association, and that staff files are incomplete:

Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is hereby cited per 22 CCR Section 87355(e)(2) and 87412(a)(11). A civil penalty in the amount of $100 per day for a total of ten days was assessed. As this is the first violation of criminal record requirements documented at this facility, a total of five days for each day worked for each staff member is the maximum amount to be assessed. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
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Control Number 27-AS-20240321114138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAZBA CARE TUOLUMNE
FACILITY NUMBER: 342701069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/30/2024
Section Cited
CCR
87355(e)(2)
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"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ..."
This requirement was not met as evidenced by:
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Licensee agrees to read and review the requirements pertaining to criminal record clearances, and to write a statement acknowledging that criminal record transfers must be completed prior to starting work. Licensee shall provide this to LPA Moleski by the POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, S1 was working for several months without having a criminal record association at this facility, which poses an immediate health and safety risk.
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Type B
04/05/2024
Section Cited
CCR
87412(a)(11)
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"(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information ... (11) A health screening as specified in Section 87411, Personnel Requirements - General."
This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski S2's health screening by the POC due date.
vincent.moleski@dss.ca.gov
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Based on record review, S2 did not have a health screening on file, despite having worked more than seven days, which poses a potential health and safety risk.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC9099 (FAS) - (06/04)
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