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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701295
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:34:36 PM

Document Has Been Signed on 07/13/2023 02:34 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
CENTRALIZED APP UNIT, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:JAZBA GLENROYFACILITY NUMBER:
342701295
ADMINISTRATOR:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:8661 GLENROY WAYTELEPHONE:
(916) 838-1457
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 0DATE:
07/13/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shane Stumpf (Licensee/Administrator)TIME COMPLETED:
02:32 PM
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Facility Type: RCFE
Application Type: Initial
Capacity: 6
Census (if any clients in care): 0
COMP II Participants: Shane Stumpf (Licensee/Administrator)
Interview Method: Virtual interview via Microsoft Teams

On July 13, 2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Darla Neeley
LICENSING EVALUATOR NAME: Diamond Law
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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