342701295-8-8-2024-27-AS-KHOS-D83QPS-20240812122112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701295
Report Date: 08/08/2024
Date Signed: 08/08/2024 09:39:01 AM

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
03/22/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240322120718

FACILITY NAME:	JAZBA GLENROY		FACILITY NUMBER:	342701295
ADMINISTRATOR:	STUMPF, SHANE		FACILITY TYPE:	740
ADDRESS:	8661 GLENROY WAY		TELEPHONE:	(916) 838-1457
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY:	6	CENSUS: 0	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shane Stumpf		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Resident eloped from the facility due to lack of care from staff
Staff do not provide daily activities for residents
Staff did not inform resident's authorized person of incidents of elopement

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 licensee Shane Stumpf and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed one resident (R1), nine current and former staff members (S1-S9), and a resident’s responsible party (R1’s RP).

One of the nine staff members interviewed (S8) said that R1 had at one point in time eloped from the facility. S8 said that they had been told by another caregiver, S9, that R1 had escaped through a door in their bedroom and went out into the road. According to S8, staff were told not to inform R1’s RP of the incident. In an interview, S9 said R1 had never eloped from the facility. S6 said that R1 “probably attempted” to elope from the facility, but said staff would have tried to redirect R1.

[continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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-20240322120718

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 GLENROY	FACILITY NUMBER: 342701295
	VISIT DATE: 08/08/2024

NARRATIVE

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All nine staff members interviewed were able to describe a variety of activities that R1 participated in, such as painting, taking walks with staff, and other art projects. The majority of staff members reported that these activities were sufficient to keep R1 engaged. LPA Moleski observed during multiple previous visits R1 engaged in various kinds of activities, such as coloring and puzzles.

The department has determined the following as it relates to the allegations that a resident eloped from the facility due to lack of care from staff, that staff do not provide daily activities for residents, and that staff did not inform a resident’s authorized person of incidents of elopements:

Based on interviews, observation, 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 Stumpf.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

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