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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 03:20:07 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: 3DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff are not sufficiently trained
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 this visit.

This investigation consisted of record review. LPA Moleski reviewed personnel records for six staff members (S1-S6).

LPA Moleski observed that all six of these staff members had training records documenting 20 hours of initial training. However, none of these six staff members had documentation of completing the required 40 hours of initial training within their first four weeks of employment, per HSC Section 1569.625(b)(1). 22 CCR Section 87412(c) states that “Licensees shall maintain in the personnel records verification of required staff training and orientation.” [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-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: 06/12/2024
NARRATIVE
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The department has determined the following as it relates to the allegation that staff are not sufficiently trained:

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

This facility is hereby cited per HSC Section 1569.625(b)(1). 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
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: 3DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff falsified records
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, observation, and record review.

In an interview, a former consultant for this facility (S7) said that employees’ medical assessments were not signed by doctors and had been falsified. LPA Moleski reviewed multiple health screening reports on file for staff members of this facility and observed digital artifacts and duplicated signatures, suggesting that the reports may have been electronically manipulated during use. Several physician’s phone numbers listed on the reports were out of service. [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-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: 06/12/2024
NARRATIVE
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The same physician listed multiple different phone numbers, none of which correspond with any publicly available phone numbers for the physician’s clinic. LPA Moleski reached out several times to the clinic physician whose name appears on the reports, but did not receive any response. LPA Moleski was unable to verify if alterations were made by the physician’s office or by facility staff, and was unable to determine whether or not the signatures of the physician were legitimate or not.

The department has determined the following as it relates to the allegation that staff falsified records:

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

No deficiencies were cited regarding the above allegations. 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-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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
HSC
1569.625(b)(1)
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“The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.” This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski a 40-hour training sign-in sheet by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review, staff members did not receive the required 40 hours of initial training within their first four weeks of employment, 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