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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701295
Report Date: 09/20/2023
Date Signed: 09/20/2023 02:55:02 PM

Document Has Been Signed on 09/20/2023 02:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
09/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Shane StumpfTIME COMPLETED:
03:30 PM
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On 9/20/23 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Jazba Glenroy (RCFE) for the purpose of conducting a pre-licensing component 3 orientation. LPA met with Licensee, Shane Stumpf and together conducted the orientation.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, and Health Related Services and Conditions.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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