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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920069
Report Date: 06/21/2024
Date Signed: 06/21/2024 03:13:20 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
04/19/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240419085641
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:
06/21/2024
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Robin Sardeson, House ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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-Staff did not provide food of good quality.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 6/21/24, and met with Robin Sardeson, House Manager, to deliver complaint investigation findings regarding the above stated allegation. LPA spoke with the Licensee by phone.

During the course of the investigation, LPA conducted interviews and observed the food supply at the care home.


********************************************Continued on LIC9099-C************************************************

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
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 5
Control Number 59-AS-20240419085641
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: 06/21/2024
NARRATIVE
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Allegation: Staff did not provide food of good quality.
On 4/24/24, LPA observed the facility’s food supply. There were several food items that were observed to be past the expiration date, as well as produce that was cut and not in a covered container. Interview with staff (S2) indicated that the expired food items and cut produce was their food, however, it was in the same area that the residents’ food supply was stored.

Based on observation and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240419085641
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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (a) The total daily diet shall be of the quality(...)necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
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Licensee agrees to submit a statement of understanding. Additionally, Licensee agrees to create a plan to ensure all food items are discarded when expired, as well as ensure proper food storage and submit to LPA by the POC due date of 7/5/24.
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 Based on observation and interviews conducted, the facility had several food items that were expired and perishable items that were not in a container with a lid, which poses a potential health, safety, and personal rights violation to the 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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/19/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240419085641

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:
06/21/2024
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Robin Sardeson, House ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
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3
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9
- Licensee did not ensure an adequate supply of food is maintained and accessible at the facility.
- Staff did not provide a variety of food options.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 6/21/24, and met with Robin Sardeson, House Manager, to deliver complaint investigation findings regarding the above stated allegations. LPA spoke with the Licensee by phone.

During the course of the investigation, LPA conducted interviews and observed the food supply at the care home.


********************************************Continued on LIC9099-C************************************************

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240419085641
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: 06/21/2024
NARRATIVE
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Allegation: Licensee did not ensure an adequate supply of food is maintained and accessible at the facility.
On 4/24/24 and 6/21/24, LPA observed the facility’s food supply. The facility had the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. Interview with the staff (S1) indicated that they order groceries for the care home every week.

Allegation: Staff did not provide a variety of food options.
On 4/24/24 and 6/21/24, LPA observed a variety of food options for residents in care. Interviews with resident (R1) and staff (S2) indicated that the facility provides a good variety of food options to the residents in care. Interviews with the S1 and S2 indicated that the facility utilizes several cookbooks to provide a variety of food options to the residents during mealtimes. A daily food menu was newly implemented at the care home as well.

Based on observation and interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5