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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701069
Report Date: 05/01/2024
Date Signed: 05/01/2024 04:41:36 PM

Document Has Been Signed on 05/01/2024 04:41 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JAZBA CARE TUOLUMNEFACILITY NUMBER:
342701069
ADMINISTRATOR/
DIRECTOR:		STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:9031 TUOLUMNE DRIVETELEPHONE:
(562) 506-8473
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
05/01/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Shane StumpfTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a complaint visit. During the visit, LPA Moleski observed deficiencies as described below. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

When LPA Moleski arrived, two staff members were present (S1-S2). LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility roster. In an interview, S1 said that S1 started working at this facility in early March. S1 said S1 did not have regular shifts, and had worked at this facility for an estimated total of 10 to 20 days.

This facility is being cited per 22 CCR Section 87355(e)(2). This facility was previously cited under this same section on 3/29/24. An immediate civil penalty in the amount of $1,000 was assessed for a repeat violation. Civil penalties in the amount of $100 per day for 15 days for a total of $1,500 were also 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: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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 05/01/2024 04:41 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/01/2024 at 02:39 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAZBA CARE TUOLUMNE
FACILITY NUMBER: 342701069

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/02/2024
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: ...

(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 associate S1 through Guardian by POC due date. Licensee shall notify LPA Moleski after having done so.
vincent.moleski@dss.ca.gov
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Based on observation, interview, and record review, S1 was working in this facility for a period of TKTK days without having an appropriate clearance transferred, which poses an immediate 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
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