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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701295
Report Date: 02/21/2025
Date Signed: 02/21/2025 04:20:58 PM

Document Has Been Signed on 02/21/2025 04:20 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JAZBA GLENROYFACILITY NUMBER:
342701295
ADMINISTRATOR/
DIRECTOR:		SHANE STUMPFFACILITY TYPE:
740
ADDRESS:8661 GLENROY WAYTELEPHONE:
(916) 838-1457
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 4DATE:
02/21/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Sangeetha VipulanandaTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a quarterly monitoring visit. LPA Moleski met with facility administrator Sangeetha Vipulananda and explained the purpose of the visit.

LPA Moleski reviewed four resident files (R1-R4) and one staff file (S1). LPA Moleski reviewed two incident reports for R4. One incident report, dated 2/11/25, described a staff member providing the resident with their nighttime medications instead of their morning medications. Another report, dated 12/27/24, described R4 suffering an unwitnessed fall. LPA Moleski reviewed CCLD fax and email records and did not observe any indication that these reports had been sent in within seven days of the incidents described.

LPA Moleski toured the facility with Vipulananda and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

While inspecting medication storage areas, LPA Moleski observed two loose medication tablets at the bottom of a bin containing pill bottles and packages.

LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.
This facility is hereby cited per 22 CCR Sections 87465(a)(4), 87465(h)(5), and 87211(a)(1)(D). An exit interview was held with Vipulananda. Appeal rights and a copy of this report were left with Vipulananda.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 02/21/2025 04:20 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 03:36 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 GLENROY
FACILITY NUMBER: 342701295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2025
Section Cited
CCR
87465(a)(4)

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"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by:
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Licensee agrees to providde LPA Moleski a plan for scheduled staff training regarding medications by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview, a resident (R4) was given the wrong medications on one occasion, which poses an immediate health, safety, and/or personal rights risk.
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Type B
02/28/2025
Section Cited
CCR87465(h)(5)

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"(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers." This requirement was not met as evidenced by:
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Licensee agrees to provide a written plan to prevent future occurrences such as observed during this visit by POC due date.
vincent.moleski@dss.ca.gov
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Based on observation, medications were not stored in their originally received container, which poses an immediate health, safety, and/or personal rights risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/21/2025 04:20 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/21/2025 at 03:58 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 GLENROY
FACILITY NUMBER: 342701295

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
87211(a)(1)(D)

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"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 incident which threatens the welfare, safety or health of any resident..." This requirement was not met as evidenced by:
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Licensee agrees to provide LPA Moleski with a written plan to address reporting requirements in the future by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review, CCLD was not notified regarding two unusual incidents, which poses a potential health, safety, and/or personal rights risk.
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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:Stephen Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
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