342701295-8-8-2024-27-AS-KHOS-D83QY3-20240812123429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701295
Report Date: 08/08/2024
Date Signed: 08/08/2024 09:39:45 AM

Unsubstantiated

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
04/02/2024 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240402132940

FACILITY NAME:	JAZBA GLENROY		FACILITY NUMBER:	342701295
ADMINISTRATOR:	STUMPF, SHANE		FACILITY TYPE:	740
ADDRESS:	8661 GLENROY WAY		TELEPHONE:	(916) 838-1457
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95826
CAPACITY:	6	CENSUS: 0	DATE:	08/08/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shane Stumpf		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff mismanaged resident's medication
Resident fell due to lack of supervision
Incidents were not reported to resident's responsible party

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 licensee Shane Stumpf and explained the purpose of the visit.

This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed one resident (R1), nine current and former staff members (S1-S9), and a resident’s responsible party (R1’s RP).

LPA Moleski reviewed a resident’s (R2’s) medication administration records (MARs) for the months of December 2023 and January, February and March 2024. LPA Moleski observed that R2 occasionally received PRN anti-anxiety medication, but did not observe in these MARs any indication that R2 was overmedicated. The number of doses reflected in the MARs align with R2’s prescription for this medication. Among the staff members interviewed (S1-S9) one staff member, S3, said that they suspected R2 was given too many doses of the PRN medication. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240402132940

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: 08/08/2024

NARRATIVE

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However, S3 did not observe any instance wherein R2 was overmedicated, and based their suspicions on the behaviors of R2, who they described as “out of it.” LPA Moleski attempted to interview this resident on 7/10/24. R2 was not able to respond coherently to LPA Moleski. R2’s LIC 602, dated from May 2023, indicated that R2 has dementia. R2’s most recent appraisal at the time this complaint was opened indicated that R2 is “confused, forgetful, [and] withdrawn.” No other staff members were aware of any time that R2 had been overmedicated.

In an interview, R1’s RP said they were informed that R1 had been saying they had fallen shortly after being admitted to this facility. However, due to R1’s dementia, it was unclear to R1’s RP if the fall had occurred at this facility, or at R1’s prior placement. In an interview, R1 told LPA Moleski that they had fallen, but then appeared to become confused. R1 asked aloud if the fall had happened at this facility, or somewhere else, and was unable to provide a clear answer to LPA Moleski. Of the nine staff members interviewed, one said they had witnessed R1 fall (S9). S9 said that on two occasions they had observed R1 fall while trying to get out of bed. S9 said R1 was not injured, but “vividly” remembered the incidents being reported to R1’s RP shortly after their occurrence. R1’s RP said they had not been informed about any alleged falls until well after the fact. S9 said there was another staff member who witnessed the falls, but could not recall their name. S2 said R1 sometimes told them that they had fallen. S3 said that they were told by another staff member whose name they had forgotten that R1 had fallen, but could not verify if this were true. S6 said that R1 sometimes told people that they had fallen, but would appear confused. S6 could not verify if R1 had ever fallen.

The department has determined the following as it relates to the allegations that staff mismanaged a resident’s medication, that a resident fell due to lack of supervision, and that incidents were not reported to a resident’s responsible party:

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: 08/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC9099 (FAS) - (06/04)

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