<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701295
Report Date: 03/25/2024
Date Signed: 03/25/2024 01:50:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
03/21/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240321120503
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: 2DATE:
03/25/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shane StumpfTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff members worked at facility without criminal record association
Staff files are incomplete
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

When LPA Moleski arrived, LPA Moleski observed a caregiver present at the facility (S1). S1 was the only caregiver present. S1 had no staff file present at the facility, and was not associated to this facility. LPA Moleski reviewed files for five other employees (S2-S6).

S1 told LPA Moleski S1 had been working five days a week for three weeks. Per 22 CCR Section 87761(b)(1), a civil penalty of $100 per day shall be assessed for an employee without a criminal background association for a maximum of 30 days for a repeat violation.

[continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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 27-AS-20240321120503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAZBA GLENROY
FACILITY NUMBER: 342701295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
CCR
87355(e)(2)
1
2
3
4
5
6
7
"(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:

(1) Obtain a California clearance or a criminal record exemption as required by the Department or

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
(3) Request and be approved for a transfer of a criminal record exemption..."
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to request association for S1 by POC due date, and to provide proof to LPA Moleski of having done so.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on interview and record review, a staff member (S1) worked for 15 days without being associated to this facility, which poses an immediate health and safety risk.
8
9
10
11
12
13
14
Type A
03/26/2024
Section Cited
CCR
87405(d)(2)
1
2
3
4
5
6
7
"(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply....
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations."
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to review 22 CCR requirements for criminal background clearances, and to write a statement acknowledging the requirement to prohibit excluded persons from all facilities by the POC due date.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews and record review, the licensee allowed an excluded individual to be present in the facility, and repeatedly allowed staff without appropriate background clearances to work in the facility, which poses an immediate health and safety risk.
8
9
10
11
12
13
14
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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240321120503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JAZBA GLENROY
FACILITY NUMBER: 342701295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
Section Cited
CCR
87405(d)(5)
1
2
3
4
5
6
7
"(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. ... (5) Good character and a continuing reputation of personal integrity."
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee shall draft a letter to all staff informing them of their obligation to identify themselves to CCLD representatives accurately and truthfully.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews, the licensee does not have a reputation for integrity among staff, which poses an immediate health, safety, and/or personal rights risk.
8
9
10
11
12
13
14
Type B
04/08/2024
Section Cited
CCR
87412(a)
1
2
3
4
5
6
7
"(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:"
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to complete all files for re-inspection by POC due date.
vincent.moleski@dss.ca.gov
8
9
10
11
12
13
14
Based on record review, S1 did not have a staff file, and other staff files were not complete, which poses a potential health, safety, and personal rights risk.
8
9
10
11
12
13
14
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: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240321120503
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JAZBA GLENROY
FACILITY NUMBER: 342701295
VISIT DATE: 03/25/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This facility was previously cited for staff without criminal record associations on 2/12/24. A civil penalty in the amount of $1000 will also be assessed due to the repeat violation.

In an interview, Stumpf said that an individual (S7) had been working in this facility as a consultant. Stumpf said that this individual was last in this facility on 3/21/24 or 3/22/24. Stumpf said S7 was physically present in this facility three days. LPA Moleski reviewed a lifetime exclusion order for S7 which took effect on March 4, 2024. LPA Moleski provided a copy of this order to Stumpf, and to S7. Per HSC Section 1548(c)(7), the presence of an excluded individual shall result in an immediate $500 civil penalty and an additional $100 per day for each day present.

In an interview, S7 said S7 had been physically present in this facility and had provided direct care to residents. S7 also said that multiple other staff members worked without criminal record associations, and that Stumpf had told staff to lie to CCLD personnel by saying they were family members of residents, or to flee the facility if CCLD were to arrive unannounced. S1 said that S1 had been told to give LPA Moleski a false name, and to say that S1 did not provide any care. S1 provided LPA Moleski a false name, before admitting to S1’s actual name.

The department has determined the following as it relates to the allegations that staff members worked at the facility without criminal record association, and that staff files are incomplete:

Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87412(a), 87355(e)(2), 87405(d)(2), and 87405(d)(5). A civil penalty of $100 per day for 3 days is hereby assessed due to the presence of an excluded individual, for a total of $300. An immediate civil penalty in the amount of $500 is hereby assessed for the presence of an excluded individual. A civil penalty in the amount of $1000 is hereby assessed for a repeat violation of criminal background clearance requirements. A civil penalty in the amount of $100 per day for 15 days is hereby assessed for the presence of an non-associated employee. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5