342701069-11-13-2025-27-AS-SRIN-DP7P33-20251209095648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701069
Report Date: 11/13/2025
Date Signed: 11/13/2025 02:54:30 PM

Unsubstantiated

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

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250714090127

FACILITY NAME:	JAZBA CARE TUOLUMNE		FACILITY NUMBER:	342701069
ADMINISTRATOR:	SANGEETHA VIPULANANDA		FACILITY TYPE:	740
ADDRESS:	9031 TUOLUMNE DRIVE		TELEPHONE:	(562) 506-8473
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY:	6	CENSUS: 6	DATE:	11/13/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Brittany McCoy		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained a fracture while in care due to staff neglect
Staff did not seek medical attention for resident in a timely manner

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 senior house manager Brittany McCoy and explained the purpose of the visit.

The Community Care Licensing Division (CCLD) received an incident report on 7/11/25 regarding a resident’s (R1’s) unwitnessed fall. According to the report, R1 fell on 7/9/25 around 6:20 a.m., but was not complaining of pain, and did not present any apparent injuries upon inspection. R1 was sent to the emergency room on 7/10/25 around 4:45 p.m. after they began to complain of pain to a family member, according the report. Medical records obtained by CCLD indicated that R1 was diagnosed with a fracture of their pubic bone.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 11/13/2025

NARRATIVE

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In an interview, R1’s responsible party (R1’s RP) said that facility administrator Sangeetha Vipulananda called them after R1 fell on 7/9/25, and was told that R1 was fine and not complaining of pain. R1’s RP said they spoke with R1 over the phone the next day, 7/10/25, and R1 began complaining of pain. R1’s RP requested staff to have R1 sent to the hospital on 7/10/25.

In an interview, a staff member on duty at the time of R1’s fall (S1) said that they observed another resident (R2) enter into R1’s room on the morning of 7/9/25. When S1 redirected R2 from R1’s room, S1 observed R1 on the floor near their bed. According to S1, R1 said that they became scared when R2 entered their room, and fell out of bed as a result. S1 said they assisted R1 up and conducted a body check, but observed no obvious signs of injury. S1 provided CCLD with a photograph taken of R1’s back, which appeared grossly unremarkable. According to S1, R1 did not complain of pain throughout 7/9/25 and 7/10/25. A second staff member on duty at the time did not appear for a scheduled interview with CCLD.

In an interview, R1 was able to recall their fall. “I was asleep and rolled out of bed,” R1 said. R1 did not remember being in pain after their fall. Medical records obtained by CCLD indicate that R1 told first responders who arrived at the facility on 7/10/25 that they did not initially experience pain after their fall, but they were experiencing pain when trying to move their leg on 7/10/25. R2 was not able to recall R1’s fall and did not have pertinent information to share with CCLD.

The department has determined the following as it relates to the allegations that a resident sustained a fracture while in care due to staff neglect, and that staff did not seek medical attention for a resident in a timely manner:

Based on interviews 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 McCoy.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025

LIC9099 (FAS) - (06/04)

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