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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920069
Report Date: 06/13/2024
Date Signed: 06/13/2024 02:33:47 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
04/17/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240417105936
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: 4DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver and Admin assistantTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9

-Staff do not ensure resident records properly maintained
-Licensee does not ensure that staff are conducting emergency drills
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced at the care home today, 6/13/24, and met with the House Manager, Janessa Reyes and Admin assistant Sangeetha Vipulananda to continue a complaint investigation into the above stated allegations. Administrator, Shane Stumpf, was notified and arrived to assist

During today's visit, LPA conducted interviews with staff present and Administrator. LPA reviewed PRN documentation records and emergency drill records.
Records review for R1 found 6/11/24 PRN not properly documented, R2 6/8/24 and 6/10/24 PRN not properly documented and R3 twice daily drops only documented once daily.
Administrator acknowledged in statements that the requirement was not met. LPA and Admin discussed the documentation requirement and implementation of the proper documentation as the plan of correction.

LPA requested documentation of proof of quarterly emergency drills on each shift and shall include, at a minimum, all direct care staff. While emergency procedures are in place, proof of actual drills is not in
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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 4
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
04/17/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240417105936

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: 4DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver and Admin assistantTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Administrator is not on the premises a sufficient number of hours to permit adequate attention to the facility
INVESTIGATION FINDINGS:
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2
3
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5
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7
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9
10
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12
13
Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced at the care home today, 6/13/24, and met with the House Manager, Janessa Reyes and Admin assistant Sangeetha Vipulananda to continue a complaint investigation into the above stated allegations. Administrator, Shane Stumpf, was notified and arrived to assist

LPA interviewed the Administrator. The Administrator stated that team leaders and managers were in place to carry out specific facility operations. The Administrator was reported to oversee the managers and was not made aware of all facility compliance not carried out by managers.
While the Administrator was not physically present at this location at all times, managers, caregivers, residents and families could reach the Adminstrator when Administrator was not present

Due to insufficient information available at this time, the above stated allegations need further investigation.

Exit interview conducted and a copy of report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 59-AS-20240417105936
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: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
87705(k)(3)
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Care of Persons with Dementia- Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
This requirement was not met based on records and interviews
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Licensee will submit a schedule of staff working at this location 6/14/24- 6/21/24 as will as emergency drill reports that those who worked participated in drills.

The documentation will be submitted by the POC date of 6/21/24.
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which found that drills were not conducted as required.

This posed a potential risk to residents.
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Type B
06/21/2024
Section Cited
CCR
87465(c)(3)
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Incidental Medical and Dental Care-(c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement was not met based on records review and interviews.
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Licensee will institute the required documentation and submit the PRN log for each current resident, to CCL by the POC date of 6/21/24
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Interviews found a lack of understanding odf the requirement and 3 of 4 resident medication records found PRN medications dispensed without the required documentatiuon.
This posed a potential risk to residents.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20240417105936
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: 06/13/2024
NARRATIVE
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place for the period of this investigation. Licensee will initiate the required drills and staff will participate as a plan of correction.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with designee. Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4