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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:02:11 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
04/19/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240419113158
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: 3DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff does not ensure disaster drills are being conducted
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

This investigation consisted of interviews and record review. According to Stumpf, emergency disaster drills have been conducted during staff meetings, which were not mandatory for all staff to attend. The drills were not conducted during each consecutive shift, but staff members of all shifts were invited to attend.

LPA Moleski reviewed staff meeting agendas from February 2022 to present. For the year of 2022, LPA Moleski observed four staff meeting agendas from February, May, July, and November. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 5
Control Number 27-AS-20240419113158
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: 06/12/2024
NARRATIVE
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The agendas indicate emergency disaster topics such as storms, blackouts, and fire safety were discussed at each. A list of attendees is provided at each. Staff schedules and employee sign-in sheets from various dates were provided by Stumpf to verify attendance. The February meeting shows four staff members attended out of six staff members employed in the same month, per employee sign-in sheets. The May meeting shows five staff members attended out of seven staff members employed in the same month, per staff schedules. The July meeting shows five staff members attended out of six staff members employed in the same month, per staff schedules. The November meeting shows five staff members attended out of seven staff members employed in the same month, per staff schedules.

For the year of 2023, LPA Moleski was provided staff meeting agendas from January, February, April, July, and October. The January meeting agenda indicates blackout and power outages were discussed, however, there is no list of staff in attendance. The meeting agendas for February, April, and October indicated emergency disaster topics were discussed and provided lists of attendees. The meeting agenda for October does not indicate any emergency disaster topics were discussed.

For the year of 2024, LPA Moleski observed two staff meeting agendas. The first, from January 2024, did not contain a list of staff in attendance, and did not indicate that any emergency disaster topics were discussed. The second agenda, from April, contained a list of staff in attendance and indicated that a fire training was held.

The department has determined the following as it relates to the allegation that staff do not ensure disaster drills are being conducted:

Based on record review, 2022 emergency disaster drills were conducted, but not for all staff members of each shift as required, and, for the years of 2023 and 2024, drills were not conducted every quarter as required. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

This facility is hereby cited per HSC Section 1569.695(c). An exit interview was held with Stumpf. 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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/19/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240419113158

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: 3DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility does not have sufficient amount of food for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

This investigation consisted of observations, interviews, and record review.

LPA Moleski visited this facility to investigate this complaint on 4/22/24 and 5/1/24. LPA Moleski observed an adequate two-day supply of perishable food and an adequate seven-day supply of non-perishable food. LPA Moleski reviewed food receipts and online food orders for this facility dating from February to April 2024 and observed a sufficient amount of food having been ordered. LPA Moleski interviewed four staff members (S1-S4). Three of the four staff members said there is always an abundance of food at the facility and did not voice any concerns regarding food shortages or issues ordering food. One former staff member said there was not enough food. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240419113158
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: 06/12/2024
NARRATIVE
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The department has determined the following as it relates to the allegation that the facility does not have a sufficient amount of food for residents:

Based on observations, interviews, and record review, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Stumpf.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240419113158
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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
HSC
1569.695(c)
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“A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.” This requirement was not met as evidenced by:
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Licensee agrees to provide a staff meeting template containing spaces to complete required emergency disaster information for each quarter and agrees to send LPA Moleski a copy by the POC due date.
vincent.moleski@dss.ca.gov
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Based on record review, the licensee did not comply with the above section, 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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5