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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 07/15/2025
Date Signed: 07/15/2025 03:40:40 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
07/14/2025 and conducted by Evaluator Vincent Moleski
COMPLAINT CONTROL NUMBER: 27-AS-20250714090127
FACILITY NAME:JAZBA CARE TUOLUMNEFACILITY NUMBER:
342701069
ADMINISTRATOR:SANGEETHA VIPULANANDAFACILITY TYPE:
740
ADDRESS:9031 TUOLUMNE DRIVETELEPHONE:
(562) 506-8473
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 6DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sangeetha VipulanandaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee is operating beyond the scope of license
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 Sangeetha Vipulananda and explained the purpose of the visit.

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

LPA Moleski reviewed a resident's file (R1). LPA Moleski observed that they had an admission agreement for another facility, but not this facility. LPA Moleski reviewed an incident reporting an unwitnessed fall suffered by R1. According to the incident report, R1 was admitted to this facility on 7/5/25 and was sent to the hospital on 7/10/25. Vipulananda said that R1 did not return to this facility after hospitalization.

LPA Moleski reviewed the files of six current residents (R2-R7). [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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-20250714090127
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: 07/15/2025
NARRATIVE
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Four of these residents had signed admission agreements from this facility. R2 was admitted on 5/14/25, R3 was admitted on 10/8/24, R4 was admitted on 2/3/24, and R5 was admitted on 12/28/23, according to their respective admission agreements.

Two current residents (R6-R7) who moved in recently had admission agreements from their prior placements, which are also owned and operated by the licensee of this facility. LPA Moleski reviewed medication administration records for R6 and R7. LPA Moleski observed signatures present for both of these residents from a certain staff member (S1) as early as 7/7/25. Vipulananda confirmed that S1 does not work at any other facilities owned or operated by the licensee of this facility. This indicates both R6 and R7 were moved in to this facility as of 7/7/25 at the latest.

LPA Moleski interviewed two staff members who were working at this facility over the past two weeks (S1-S2). Both S1 and S2 confirmed that R1-R7 were living at the facility at the same time. Both S1 and S2 said that R1 was living in a staff room on a spare bed, along with the live-in staff member.

This facility's license permits the licensee to provide care for no more than six residents at any given time.

The department has determined the following as it relates to the allegation that the licensee is operating beyond the scope of license:

Based on interviews and record review, 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 22 CCR Section 87204(a). An exit interview was held with Vipulananda. Appeal rights and a copy of this report were left with Vipulananda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20250714090127
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: 07/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2025
Section Cited
CCR
87204(a)
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"(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time..." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with a written acknowledgment of the limitations of this facility's license by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, seven clients were residing in this facility concurrently, despite the fact that this facility's license is for six residents only, which poses an immediate health, safety, and/or personal rights 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: 07/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
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