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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701295
Report Date: 06/28/2024
Date Signed: 07/02/2024 04:49:32 PM

Document Has Been Signed on 07/02/2024 04:49 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JAZBA GLENROYFACILITY NUMBER:
342701295
ADMINISTRATOR/
DIRECTOR:		STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:8661 GLENROY WAYTELEPHONE:
(916) 838-1457
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 4DATE:
06/28/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Shane StumpfTIME VISIT/
INSPECTION COMPLETED:
11:15 PM
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A non-compliance conference was held today, June 28, 2024, in order to discuss substantiated complaints and other serious deficiencies identified by the department. Licensing Program Analyst (LPA) Vincent Moleski, Licensing Program Manager (LPM) Stephen Richardson, Regional Manager (RM) Stephenie Doub, licensee/administrator Shane Stumpf, and Stumpf's executive assistant Sangeetha Vipulananda were in attendance.

RM Doub discussed operational and administrative concerns which have been reflected in substantiated complaints, such as acquiring criminal record clearances for new employees and completing the required amount of staff training during onboarding. Stumpf said that she has hired Vipulananda to assist with administrative tasks, and has worked to create checklists and task sheets to streamline these tasks.

Stumpf she had not been able to provide sufficient oversight over her facilities, resulting in deficiencies. RM Doub recommended that Stumpf appoint administrators to her facilities in order to delegate administrative tasks while still maintaining oversight over operations. Stumpf agreed, and identified several individuals who may be able to act as administrators.

RM Doub offered Technical Support Program referral, to which Stumpf agreed.

RM Doub requested that Stumpf provide an updated LIC 500 for her facilities reflecting real hours worked by Stumpf and others, and to appoint administrators to delegate administrative tasks to. Stumpf agreed to provide CCLD a written plan identifying those individuals who are able to be appointed as facility administrators immediately, if any. For those staff members who are still completing their administrator certificates, Stumpf agreed to appoint them as designees and to create job duties for an "assistant administrator" position. [continued on 809-C]
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GLENROY
FACILITY NUMBER: 342701295
VISIT DATE: 06/28/2024
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The Licensee shall identify these assistant administrators by name and facility, and shall include a written job description with a full listing of their role and responsibilities. Stumpf agreed to provide this plan, LIC 308s for all designees identified, and updated LIC 500s for her facilities by July 8. Stumpf shall also submit the following for any individuals already holding an administrator certificate who are to be appointed facility administrator of record: An LIC 200 indicating change of administrator, an LIC 308, the individual's complete personnel file, proof of education, and a copy of their administrator certificate.

RM Doub advised that this facility will be receiving increased monitoring in the form of quarterly visits. No deficiencies were cited during this meeting. An exit interview was held with Stumpf, and a copy of this report was sent to her to sign.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024
LIC809 (FAS) - (06/04)
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