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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920069
Report Date: 04/24/2024
Date Signed: 04/24/2024 06:50:41 PM

Document Has Been Signed on 04/24/2024 06:50 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JAZBA CARE STAMP MILLFACILITY NUMBER:
345920069
ADMINISTRATOR/
DIRECTOR:		STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:2625 STAMP MILL COURTTELEPHONE:
(916) 838-1457
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
04/24/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Edith Spiveyhorn, Lead StaffTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and initially met with with care staff, Kerry Parchmont and Nancy Carr. Edith Spiveyhorn, Lead Staff, arrived at approximately 2:-00 pm.

During the course of complaint investigation (59-AS-20240321145120), it was discovered that an incident report was not submitted timely to the Department following a resident's (R1)'s fall at the facility on 3/9/24. An incident report was submitted for the incident on 4/8/24, after the Department requested it be.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited on the 809-D page.

Exit interview with Lead Staff as Administrator was not available during this time. Copy of report and appeal rights provided to the Administrator.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 06:50 PM - It Cannot Be Edited


Created By: Sabrina Calzada On 04/24/2024 at 06:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
CCR
87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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A completed incident report was submitted on 4/8/24 to the Department.

Licensee/Administrator agree to read Regulation 87211 and send a signed statement to the Departent by 5/8/24.
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Based on interviews and review of the Department's files, an incident report was not submitted for resident (R1) following a fall on 3/9/24, which posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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