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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701295
Report Date: 05/30/2024
Date Signed: 05/30/2024 10:12:56 AM

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: 4DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shane StumpfTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff are not sufficiently trained
Resident was allowed access to knives
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

This investigation consisted of interviews and record review.

LPA Moleski opened this complaint investigation on 3/25/24. LPA Moleski interviewed a staff member (S1) who did not have a staff file, and did not have any training records available. During the interview with S1, S1 said they had been working at the facility for about three weeks. During the same interview, LPA Moleski asked what sort of training S1 had received prior to starting work. S1 said that S1 had received training out-of-state prior to starting work, and was showed how to complete daily tasks by other staff members. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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
VISIT DATE: 05/30/2024
NARRATIVE
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LPA Moleski was told by a former consultant of this facility (S7) that a resident (R1) was allowed to cook with and wash kitchen knives. LPA Moleski observed a photograph which depicted R1 standing in front of an open drawer containing large kitchen knives. R1 is shown leaning over and either removing a spoon or returning it to the drawer. In an interview, Stumpf said that R1 liked to help put dishes away. Stumpf said that since this matter was brought to her attention, the drawers were rearranged so that knives were kept elsewhere. LPA Moleski reviewed R1’s file. R1 has dementia, according to an LIC 602 dated 10/6/23.

The department has determined the following as it relates to the allegations that staff are not sufficiently trained and that a resident was allowed access to knives:

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 87705(f)(1) and 87412(c). 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 4DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shane StumpfTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff falsified records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review.

In an interview, a former consultant for this facility (S7) said that employees’ medical assessments were not signed by doctors and had been falsified. LPA Moleski reviewed multiple health screening reports on file for staff members of this facility and observed digital artifacts and duplicated signatures, suggesting that the reports may have been electronically manipulated during use. Several physician’s phone numbers listed on the reports were out of service. [continued on 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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: 05/30/2024
NARRATIVE
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The same physician listed multiple different phone numbers, none of which correspond with any publicly available phone numbers for the physician’s clinic. LPA Moleski reached out several times to the clinic physician whose name appears on the reports, but did not receive any response. LPA Moleski was unable to verify if alterations were made by the physician’s office or by facility staff, and was unable to determine whether or not the signatures of the physician were legitimate or not.

The department has determined the following as it relates to the allegation that staff falsified records:

Based on interviews, observation, and record review, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Stumpf.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 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: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87705(f)(1)
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“(f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).” This requirement was not met as evidenced by:
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Licensee has previously removed knives from the drawer and to a separate locked storage area. This POC will be cleared.
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Based on interviews and record review, a resident was allowed access to knives, which poses an immediate health and safety risk.
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Type B
06/13/2024
Section Cited
CCR
87412(c)
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“(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.” This requirement was not met as evidenced by:
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Licensee agrees to write a signed statement of acknowledgement of the requirements regarding staff training records, and shall send a copy to LPA Moleski by POC due date.
vincent.moleski@dss.ca.gov
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Based on interviews and record review, S1 had no staff training records on file, 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5