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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701295
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:03:20 PM

Document Has Been Signed on 02/12/2024 01:03 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:STUMPF, SHANEFACILITY TYPE:
740
ADDRESS:8661 GLENROY WAYTELEPHONE:
(916) 838-1457
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY: 6CENSUS: 6DATE:
02/12/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shane StumpfTIME COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

Three staff members (S1-S3) were present in the facility upon arrival (S1-S3). None of these three staff members were associated to this facility's roster. Stumpf submitted transfer documents to the Community Care Licensing Division during this visit. LPA Moleski reviewed six resident files (R1-R6) and seven staff files (S1-S7).

LPA Moleski toured the facility with Stumpf 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 120 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

LPA Moleski observed 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.

LPA Moleski interviewed one staff member (S4) and one resident (R3).

This facility is being cited per 22 CCR Section 87355(e)(2). An exit interview was held with Stumpf. Appeal rights and a copy of this report was left with Stumpf.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 02/12/2024 01:03 PM - It Cannot Be Edited


Created By: Vincent Moleski On 02/12/2024 at 12:53 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: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ...
(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) ..."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not ensure three staff members were associated to this facility prior to starting work, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee submitted transfer documents to CCLD during this visit. This POC will be cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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