<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920069
Report Date: 04/24/2024
Date Signed: 04/24/2024 06:53:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/21/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240321145120
FACILITY NAME:JAZBA CARE STAMP MILLFACILITY NUMBER:
345920069
ADMINISTRATOR:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:2625 STAMP MILL COURTTELEPHONE:
(916) 838-1457
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Edith Spiveyhorn, House Manager TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not properly trained
Staff files are incomplete
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 3/21/24. LPA met with care staff, Kerry Parchmont and Nancy Carr. LPA spoke with Administrator, Shane Stumpf, by phone, who stated she was not able to attend today's inspection. LPA Angela Hood arrived at 2:00 pm to conduct a separate inspection. Staff Edith Spiveyhorhn arrived just prior to 2:00 pm.

During the course of the of the investigation, LPA interviewed the Administrator and (3) staff members. LPA reviewed (3) staff files and documentation related to resident (R1). LPA also reviewed medications being administered and the related documentation for (2) residents.


The results of the investigation are as follows:





Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
VISIT DATE: 04/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099C-1... Allegation: Staff are not properly trained. The complaint alleges staff are not trained and that training documentation is false.

LPA requested all staff files be made available for review since they were not accessible when LPA was at the facility on 3/27/24. The Administrator stated the files were in electronic/PDF format on her laptop which was at another location during the inspection on 3/27/24.

The administrator emailed LPA (3) staff files for staff (S1, S2 and S3) on 4/8/24. All (3) staff had current First Aid/CPR certifications on file, but there was no documentation that staff (S1) or (S3) had completed the required initial and/or continuing training related to ADL's or medication administration. LPA observed documentation that (S2) had completed hospice care and Dementia care training in April 2024.

LPA requested to review the remaining staff files on 4/24/24, but the files were not able to be accessed due to the Administrator being the only one who has access; however, LPA confirmed that (S4) completed First Aid/CPR certification prior to beginning to work at the facility.

Based on the the training documentation that was viewed, the part of the allegation about documentation being "false" is not able to be substantiated. Based on (3) staff files that were able to be reviewed and the remaining staff files that were not able to be reviewed to confirm that all staff have completed all required training, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Allegation: Staff files are incomplete. The complaint alleges staff health screenings are not completed and the criminal record statements are not signed.

LPA reviewed health screenings and criminal record clearances for (6) staff files. (5) of (6) criminal record clearances were signed. LPA observed staff (S6) sign the LIC508 during the inspection on 4/17/24. Health screenings for (3) staff (S2, S5 and S6) appeared that some parts were photocopied and used more than once.

Based on documentation reviewed, LPA finds the allegation to be SUBSTANTIATED- meaning the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview. Copy of report and appeal rights provided to the House Lead.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
03/21/2024 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240321145120

FACILITY NAME:JAZBA CARE STAMP MILLFACILITY NUMBER:
345920069
ADMINISTRATOR:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:2625 STAMP MILL COURTTELEPHONE:
(916) 838-1457
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Edith Spiveyhorn, House Manager TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not seek timely medical treatment for resident in care.
Licensee has staff working without a criminal record clearance.
Facility is not keeping medications locked away.
Facility is not keeping sharps locked away.
Residents are not being provided safe furniture
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Calzada arrived unannounced on 4/24/24 to conclude the investigation and deliver findings. During the course of the investigation, LPA interviewed multiple staff and reviewed documentation. LPA also toured the facility on 3/27/24, 4/17/24 and on 4/24/24. The results of the investigation are as follows:

Allegation: Facility did not seek timely medical treatment for resident in care. The complaint allegation states that resident (R1) fell and sustained injuries due to a chair that the licensee and staff knew was broken. Facility did not seek timely medical for (R1) who is now on hospice and declining.

Hospital discharge papers show resident (R1) received medical care on 3/9/24 for a fall that occurred at the facility and was treated for a hematoma, or head injury, of the forehead. The incident report submitted to the Department, on 4/8/24, states that (R1) had an unwitnessed fall in her room, on 3/9/24, while the caregiver was present but had her back turned as she was getting clothes from resident’s closet.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
VISIT DATE: 04/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099A-C-1... The incident report notes resident fell from her bed and sustained the fall; however, the Administrator stated staff, (S7) initially told her (R1) fell from her bed but then later said she was "not sure."
Staff, (S2), stated she was present on 3/9/24 when resident fell and stated she was told by (S7) that (R1) fell from the chair in her room and not from the bed. Resident's family member stated she was also told by a staff member that resident fell from the chair. (S2) stated she was the one who immediately called the Administrator to report the fall and resident was sent out to the emergency room promptly. The Administrator stated the resident was sent to the Emergency Room once she was made aware of the fall by the caregiver, an hour later. The report notes resident returned from the hospital (4) hours later to the facility.

(R1) was placed on hospice care on 3/15/24 due to a terminal diagnosis of cerebral atherosclerosis. Hospice notes also document that resident had “extensive bruise to face” and “head bump to left forehead”. Resident’s current physician’s report (Dec 2023) notes resident has a primary diagnosis of Syncope and Collapse and congestive heart failure and is noted as being non-ambulatory based on physical condition. Resident was given an order for oxygen, as needed, for shortness of breath and comfort, on 3/16/24. Staff indicated that (R1) will wobble when sitting in a chair and needs a reclining wheelchair to sit in.

Resident’s responsible person stated(R1) started to have trouble breathing- she had "very labored breathing" and on the day she visited following the fall, a geriatric nurse from the hospital was there. The family member stated (R1) was "slumped over in her chair" and discussed possibly starting resident on hospice with the nurse, and the nurse agreed stating it may be better for (R1) if she does start hospice, explaining she and the Administrator previously discussed how (R1)"will fight going to the Emergency Room every time, and if she is on hospice, she doesn't have to go" as the facility can contact hospice personnel to come out. The responsible person stated she observed a staff member to be sitting in the same chair in (R1's) room when she visited a few days after the fall, and she did not observe any part of the chair to be broken. LPA did not observe any furniture to be broken or in disrepair on (3) separate occasions during the investigation. The staff (S7) who was present during the incident is no longer employed at the facility and was not able to be interviewed.

Based on interviews conducted and documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


*cont on 9099A-C-2...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
VISIT DATE: 04/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099A-C-2... Licensee has staff working without a criminal record clearance. The complaint alleges that 6 staff are not associated to the facility and the licensee will have staff working before receiving criminal background clearance.

On 3/27/24, LPA and the Administrator discussed current staff associations, per the Department's fingerprint clearance system.. The Administrator showed LPA an email from a support staff from the Department who had recently been assisting with associating the (2) most recent staff. LPA was later provided with documentation of fingerprint clearance.

On 4/17/24, LPA confirmed that both staff present, staff (S2 and S5) were associated on 3/18/24 and on 4/8/24. LPA was provided with additional printed clearances for multiple staff for (2) related facilities on 4/24/24.

Based on documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.




Allegation: Facility is not keeping medications locked away. Complaint alleges that medications are not locked away.

LPA observed that medications were locked in the medication room during each of (3) inspections conducted and medications are prepared for the day only. LPA also did not observe any medication to be unsecured in the common areas or resident rooms during all inspections also.

LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


*cont on 9099A-C-3...
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
VISIT DATE: 04/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099A-C-3.. Allegation: Facility is not keeping sharps locked away. The complaint alleges resident (R2) has access to razors and cut himself and the licensee refuses to lock razors away because resident does not have Dementia. Also alleges knives are not locked in the kitchen.

Resident (R2) stated he uses both an electric razor and a manual razor and he is able to shave himself independently. Staff stated they provide standby assistance for (R2) who uses both types of razors- electric and manual with staff stating they are not aware that (R2) has ever cut himself. One staff stated a family member will allow R2 to use his electronic razor independently and that caused him to cut himself.

Administrator stated R2's family member will often bring razors over for resident to use and place them in the resident's bathroom without staff's knowledge. Staff will now look in the bathroom following each visit. LPA observed (2) razors to be in a bathroom drawer on 4/17/24 and the Administrator immediately removed the razors and locked them up. Administrator stated that all staff will accompany residents into the bathroom. LPA observed there were no unlocked razors on 4/24/24. R2 does not have a diagnosis of Dementia.

LPA observed where sharps to be locked in the kitchen on (3) occasions. LPA observe the drawer to be locked bya magnetic. LPA also observed markings on the drawer where the previous combination lock was previously used. The Administrator stated she prefers the combination lock as there is not a key or magnetic piece that could be misplaced.

Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Residents are not being provided safe furniture. Complaint alleges resident (R1) fell and sustained injuries due to a chair that the licensee and staff knew the chair was broken.

LPA toured (3) occasions and did not observe any broken chair or other furniture. All interviews conducted confirmed that no staff was aware that (R1's) chair was broken with a family member stating she visited resident on 3/14/24 and observed the same chair to be in the room as usual and it did not appear to be broken, stating that another care staff/woman was sitting in the chair folding laundry during her visit.

Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. **cont on 9099A-C 4-..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
VISIT DATE: 04/24/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
9099A-C-4....Allegation: Facility is not providing medications as prescribed. The complaint alleges that medications are not being given as prescribed.

LPA and staff(S2) reviewed medications for (1) resident (R3) on 4/17/24. Medications are being administered as ordered. R3's family member brought several bottles of vitamins that do not have an order yet from the doctor. The facility has reached out multiple times to the doctor to request orders before they can administer any.

LPA Calzada and LPA Angela Hood reviewed medications for resident (R2) on 4/24/24 with staff,(S3). All medications are being administered as ordered and are being documented correctly on the Medication Administration Record (MAR). There was (1) PRN medication- Albuterol 108 (90 Base) that (R2) does not ask for that was not on hand currently. Facility will reach out to the doctor tomorrow and request the medication or obtain a discontinuance order.

All staff interviewed indicated that medications are being given as ordered and a medication cannot be given until there is an order on hand.

Based on interviews and medication review, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.


Copy of report provided to the Administrator Designee, Edith.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 59-AS-20240321145120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAZBA CARE STAMP MILL
FACILITY NUMBER: 345920069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
ILS
1569.625
1
2
3
4
5
6
7
(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agrees to provide documentation of completed staff training by 5/8/24- fax or email to the Department.
8
9
10
11
12
13
14
Based on staff files that were reviewed and staff files that were not available, the Licensee did not ensure that all staff have completed the required initial/continuing training, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
05/08/2024
Section Cited
CCR
87412(d)
1
2
3
4
5
6
7
87412 Personnel Records. (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator agree to ensure that each staff has a complete personnel record per Regulation 87412 and all staff records are maintained on site.
Signed statement that Reg 87412 has been read and understood. LPA Hood to check staff files during a future visit.
8
9
10
11
12
13
14
Based on staff and administrator's statements, not all staff files were present and available for review and the (3) that were reviewed did not have all of the requirement documentation, which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8