Jazba Care Stamp Mill

Allegation investigated: Licensee does not ensure staff are first aid certified. Licensee does not ensure staff have a tuberculosis certification.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 9/1/26 to do complaint investigation for above allegations. LPA was greeted by staff and staff called Administrator, Shane Stumpf who came to the facility after short while. LPA explained the purpose of today's visit. The department conducted records review ,facility observations and interviews to investigate the complaint. Administrator interview indicated that staff files were complete and maintained per Regulations and there were no issues. Record review indicated that staff files contain all required documents including Current CPR/First Aid certification, TB Clearance and other required paperwork and found them to be complete and organized. Based on these findings, these allegation are considered UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility. Unfoundedthe state’s words, verbatim · CDSS document, Sep 1, 2026 · control 59-AS-20260831120222

Allegation investigated: Staff mismanage resident's medication. Facility is not sufficiently staffed to meet the needs of residents in care. Staff do not provide a safe and comfortable environment for residents.

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 7/27/26 to do complaint investigation for above allegations. LPA was greeted by staff and staff called Administrator, Shane Stumpf who came to the facility after short while. LPA expained the purpose of today's visit. The department conducted records review ,facility observations and interviews to investigate the complaint. **Report continued on LIC9099-C** Unfounded **Report continued from 9099... Allegation- Staff mismanage resident's medication. UNFOUNDED Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews with two (2) staff and three (3) residents. It was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. A review of the records for the month of July 2026, indicated that the facility maintained a proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Staff interviews reflected that residents were given medications on time per their physician’s orders and there were no problems to address. Based on these findings, this allegation is considered UNFOUNDED. Allegation- Facility is not sufficiently staffed to meet the needs of residents in care. UNFOUNDED Record review and staff interviews indicated that there are 2 caregivers for day shift and 1 caregiver for night shift who works daily to meet residents needs. Interviews did not indicate any staffing concerns at the facility. Based on these findings, this allegation is considered UNFOUNDED. Allegation- Staff do not provide a safe and comfortable environment for residents. UNFOUNDED Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. Residents interviews reflected that facility was providing safe and comfortable environment to them and there were no issues to address. Staff interviews reflected that there were no complaints in this area. Facility tour conducted on 7/27/27 indicated that facility was providing safe environment to residents per Regulations and there were no concerns. Based on these findings, this allegation is considered UNFOUNDED. A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.the state’s words, verbatim · CDSS document, Jul 27, 2026 · control 59-AS-20260724093224

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Talwinder Bains arrived on 10/20/25 to conduct the annual inspection. LPA met with staff and explained the purpose of today's visit. Administrator, Sangeetha Vipulanada and House Lead, Brittany McCoy came after short while and assisted LPA with today's visit. All six residents were present during today's visit. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed medications of two (2) residents comparing with physician orders . LPA reviewed three (3) residents files and two (2) staff files. LPA and staff toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. Grab bars were present at the toilet and in the shower. All exits were unobstructed. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Hot water temperature was observed to be 111 degrees F, which is within the regulation range of 105-120 degree. LPA requested a copy of the LIC308, LIC 500, LIC610E and current liability insurance to be sent to the Department by 10/31/25. Deficiencies were observed and cited per Title 22, CCR Regulations as listed on LIC 809-D. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today. Exit interview conducted. Copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 20, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Hood arrived at the facility unannounced on 11/21/24 and met with the House Manager and Administrator to conduct a Required-1 Year Inspection. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (3) bedrooms and two (2) bathrooms for resident use. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained, and the hot water temperature was observed to be 114 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. LPA observed knives to be locked away and inaccessible to residents. LPA observed the outdoor area and perimeter of the care home to be free of clutter and debris and there appeared to be no potential safety hazards to the residents in care. Smoke and carbon monoxide detectors are operational. Fire extinguisher and first aid kits are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed four (4) resident files and also reviewed two (2) staff files. As a result of this visit, no deficiencies were cited per California Code of Regulations, Title 22. Exit interview conducted and copy of report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024

Allegation investigated: -Staff did not provide food of good quality.

Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 6/21/24, and met with Robin Sardeson, House Manager, to deliver complaint investigation findings regarding the above stated allegation. LPA spoke with the Licensee by phone. During the course of the investigation, LPA conducted interviews and observed the food supply at the care home. ********************************************Continued on LIC9099-C************************************************ Substantiated Allegation: Staff did not provide food of good quality. On 4/24/24, LPA observed the facility’s food supply. There were several food items that were observed to be past the expiration date, as well as produce that was cut and not in a covered container. Interview with staff (S2) indicated that the expired food items and cut produce was their food, however, it was in the same area that the residents’ food supply was stored. Based on observation and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiency is being cited on the attached 9099-D page. Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents. Allegation: Licensee did not ensure an adequate supply of food is maintained and accessible at the facility. On 4/24/24 and 6/21/24, LPA observed the facility’s food supply. The facility had the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. Interview with the staff (S1) indicated that they order groceries for the care home every week. Allegation: Staff did not provide a variety of food options. On 4/24/24 and 6/21/24, LPA observed a variety of food options for residents in care. Interviews with resident (R1) and staff (S2) indicated that the facility provides a good variety of food options to the residents in care. Interviews with the S1 and S2 indicated that the facility utilizes several cookbooks to provide a variety of food options to the residents during mealtimes. A daily food menu was newly implemented at the care home as well. Based on observation and interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 21, 2024 · control 59-AS-20240419085641

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jul 5, 2024

87555 General Food Service Requirements (a) The total daily diet shall be of the quality(...)necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on observation and interviews conducted, the facility had several food items that were expired and perishable items that were not in a container with a lid, which poses a potential health, safety, and personal rights violation to the residents in care.the state’s words, verbatim · CDSS document, Jun 21, 2024

Plan of correction: Licensee agrees to submit a statement of understanding. Additionally, Licensee agrees to create a plan to ensure all food items are discarded when expired, as well as ensure proper food storage and submit to LPA by the POC due date of 7/5/24.

Allegation investigated: -Staff do not ensure resident records properly maintained -Licensee does not ensure that staff are conducting emergency drills

Licensing Program Analyst (LPA) Kevin Mknelly arrived unannounced at the care home today, 6/13/24, and met with the House Manager, Janessa Reyes and Admin assistant Sangeetha Vipulananda to continue a complaint investigation into the above stated allegations. Administrator, Shane Stumpf, was notified and arrived to assist During today's visit, LPA conducted interviews with staff present and Administrator. LPA reviewed PRN documentation records and emergency drill records. Records review for R1 found 6/11/24 PRN not properly documented, R2 6/8/24 and 6/10/24 PRN not properly documented and R3 twice daily drops only documented once daily. Administrator acknowledged in statements that the requirement was not met. LPA and Admin discussed the documentation requirement and implementation of the proper documentation as the plan of correction. LPA requested documentation of proof of quarterly emergency drills on each shift and shall include, at a minimum, all direct care staff. While emergency procedures are in place, proof of actual drills is not in Substantiated place for the period of this investigation. Licensee will initiate the required drills and staff will participate as a plan of correction. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with designee. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 13, 2024 · control 59-AS-20240417105936

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(k)(3) · Plan of correction due date: Jun 21, 2024

Care of Persons with Dementia- Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement was not met based on records and interviews which found that drills were not conducted as required. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Licensee will submit a schedule of staff working at this location 6/14/24- 6/21/24 as will as emergency drill reports that those who worked participated in drills. The documentation will be submitted by the POC date of 6/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: Jun 21, 2024

Incidental Medical and Dental Care-(c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met based on records review and interviews. Interviews found a lack of understanding odf the requirement and 3 of 4 resident medication records found PRN medications dispensed without the required documentatiuon. This posed a potential risk to residents.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: Licensee will institute the required documentation and submit the PRN log for each current resident, to CCL by the POC date of 6/21/24

Allegation investigated: Staff are not properly trained Staff files are incomplete

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation for a complaint received on 3/21/24. LPA met with care staff, Kerry Parchmont and Nancy Carr. LPA spoke with Administrator, Shane Stumpf, by phone, who stated she was not able to attend today's inspection. LPA Angela Hood arrived at 2:00 pm to conduct a separate inspection. Staff Edith Spiveyhorhn arrived just prior to 2:00 pm. During the course of the of the investigation, LPA interviewed the Administrator and (3) staff members. LPA reviewed (3) staff files and documentation related to resident (R1). LPA also reviewed medications being administered and the related documentation for (2) residents. The results of the investigation are as follows: Substantiated 9099C-1... Allegation: Staff are not properly trained. The complaint alleges staff are not trained and that training documentation is false. LPA requested all staff files be made available for review since they were not accessible when LPA was at the facility on 3/27/24. The Administrator stated the files were in electronic/PDF format on her laptop which was at another location during the inspection on 3/27/24. The administrator emailed LPA (3) staff files for staff (S1, S2 and S3) on 4/8/24. All (3) staff had current First Aid/CPR certifications on file, but there was no documentation that staff (S1) or (S3) had completed the required initial and/or continuing training related to ADL's or medication administration. LPA observed documentation that (S2) had completed hospice care and Dementia care training in April 2024. LPA requested to review the remaining staff files on 4/24/24, but the files were not able to be accessed due to the Administrator being the only one who has access; however, LPA confirmed that (S4) completed First Aid/CPR certification prior to beginning to work at the facility. Based on the the training documentation that was viewed, the part of the allegation about documentation being "false" is not able to be substantiated. Based on (3) staff files that were able to be reviewed and the remaining staff files that were not able to be reviewed to confirm that all staff have completed all required training, LPA finds the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Allegation: Staff files are incomplete. The complaint alleges staff health screenings are not completed and the criminal record statements are not signed. LPA reviewed health screenings and criminal record clearances for (6) staff files. (5) of (6) criminal record clearances were signed. LPA observed staff (S6) sign the LIC508 during the inspection on 4/17/24. Health screenings for (3) staff (S2, S5 and S6) appeared that some parts were photocopied and used more than once. Based on documentation reviewed, LPA finds the allegation to be SUBSTANTIATED- meaning the allegation is valid because the preponderance of the evidence standard has been met. Exit interview. Copy of report and appeal rights provided to the House Lead. 9099A-C-1... The incident report notes resident fell from her bed and sustained the fall; however, the Administrator stated staff, (S7) initially told her (R1) fell from her bed but then later said she was "not sure." Staff, (S2), stated she was present on 3/9/24 when resident fell and stated she was told by (S7) that (R1) fell from the chair in her room and not from the bed. Resident's family member stated she was also told by a staff member that resident fell from the chair. (S2) stated she was the one who immediately called the Administrator to report the fall and resident was sent out to the emergency room promptly. The Administrator stated the resident was sent to the Emergency Room once she was made aware of the fall by the caregiver, an hour later. The report notes resident returned from the hospital (4) hours later to the facility. (R1) was placed on hospice care on 3/15/24 due to a terminal diagnosis of cerebral atherosclerosis. Hospice notes also document that resident had “extensive bruise to face” and “head bump to left forehead”. Resident’s current physician’s report (Dec 2023) notes resident has a primary diagnosis of Syncope and Collapse and congestive heart failure and is noted as being non-ambulatory based on physical condition. Resident was given an order for oxygen, as needed, for shortness of breath and comfort, on 3/16/24. Staff indicated that (R1) will wobble when sitting in a chair and needs a reclining wheelchair to sit in. Resident’s responsible person stated(R1) started to have trouble breathing- she had "very labored breathing" and on the day she visited following the fall, a geriatric nurse from the hospital was there. The family member stated (R1) was "slumped over in her chair" and discussed possibly starting resident on hospice with the nurse, and the nurse agreed stating it may be better for (R1) if she does start hospice, explaining she and the Administrator previously discussed how (R1)"will fight going to the Emergency Room every time, and if she is on hospice, she doesn't have to go" as the facility can contact hospice personnel to come out. The responsible person stated she observed a staff member to be sitting in the same chair in (R1's) room when she visited a few days after the fall, and she did not observe any part of the chair to be broken. LPA did not observe any furniture to be broken or in disrepair on (3) separate occasions during the investigation. The staff (S7) who was present during the incident is no longer employed at the facility and was not able to be interviewed. Based on interviews conducted and documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099A-C-2... 9099A-C-2... Licensee has staff working without a criminal record clearance. The complaint alleges that 6 staff are not associated to the facility and the licensee will have staff working before receiving criminal background clearance. On 3/27/24, LPA and the Administrator discussed current staff associations, per the Department's fingerprint clearance system.. The Administrator showed LPA an email from a support staff from the Department who had recently been assisting with associating the (2) most recent staff. LPA was later provided with documentation of fingerprint clearance. On 4/17/24, LPA confirmed that both staff present, staff (S2 and S5) were associated on 3/18/24 and on 4/8/24. LPA was provided with additional printed clearances for multiple staff for (2) related facilities on 4/24/24. Based on documentation reviewed, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Facility is not keeping medications locked away. Complaint alleges that medications are not locked away. LPA observed that medications were locked in the medication room during each of (3) inspections conducted and medications are prepared for the day only. LPA also did not observe any medication to be unsecured in the common areas or resident rooms during all inspections also. LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. *cont on 9099A-C-3... 9099A-C-3.. Allegation: Facility is not keeping sharps locked away. The complaint alleges resident (R2) has access to razors and cut himself and the licensee refuses to lock razors away because resident does not have Dementia. Also alleges knives are not locked in the kitchen. Resident (R2) stated he uses both an electric razor and a manual razor and he is able to shave himself independently. Staff stated they provide standby assistance for (R2) who uses both types of razors- electric and manual with staff stating they are not aware that (R2) has ever cut himself. One staff stated a family member will allow R2 to use his electronic razor independently and that caused him to cut himself. Administrator stated R2's family member will often bring razors over for resident to use and place them in the resident's bathroom without staff's knowledge. Staff will now look in the bathroom following each visit. LPA observed (2) razors to be in a bathroom drawer on 4/17/24 and the Administrator immediately removed the razors and locked them up. Administrator stated that all staff will accompany residents into the bathroom. LPA observed there were no unlocked razors on 4/24/24. R2 does not have a diagnosis of Dementia. LPA observed where sharps to be locked in the kitchen on (3) occasions. LPA observe the drawer to be locked bya magnetic. LPA also observed markings on the drawer where the previous combination lock was previously used. The Administrator stated she prefers the combination lock as there is not a key or magnetic piece that could be misplaced. Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Allegation: Residents are not being provided safe furniture. Complaint alleges resident (R1) fell and sustained injuries due to a chair that the licensee and staff knew the chair was broken. LPA toured (3) occasions and did not observe any broken chair or other furniture. All interviews conducted confirmed that no staff was aware that (R1's) chair was broken with a family member stating she visited resident on 3/14/24 and observed the same chair to be in the room as usual and it did not appear to be broken, stating that another care staff/woman was sitting in the chair folding laundry during her visit. Based on interviews and observations, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. **cont on 9099A-C 4-.. 9099A-C-4....Allegation: Facility is not providing medications as prescribed. The complaint alleges that medications are not being given as prescribed. LPA and staff(S2) reviewed medications for (1) resident (R3) on 4/17/24. Medications are being administered as ordered. R3's family member brought several bottles of vitamins that do not have an order yet from the doctor. The facility has reached out multiple times to the doctor to request orders before they can administer any. LPA Calzada and LPA Angela Hood reviewed medications for resident (R2) on 4/24/24 with staff,(S3). All medications are being administered as ordered and are being documented correctly on the Medication Administration Record (MAR). There was (1) PRN medication- Albuterol 108 (90 Base) that (R2) does not ask for that was not on hand currently. Facility will reach out to the doctor tomorrow and request the medication or obtain a discontinuance order. All staff interviewed indicated that medications are being given as ordered and a medication cannot be given until there is an order on hand. Based on interviews and medication review, LPA finds the allegation to be UNSUBSTANTIATED- meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Copy of report provided to the Administrator Designee, Edith.the state’s words, verbatim · CDSS document, Apr 24, 2024 · control 59-AS-20240321145120

From the deficiency page — Deficiency type: Type B · Section cited: ILS 1569.625 · Plan of correction due date: May 8, 2024

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on staff files that were reviewed and staff files that were not available, the Licensee did not ensure that all staff have completed the required initial/continuing training, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee/Administrator agrees to provide documentation of completed staff training by 5/8/24- fax or email to the Department.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(d) · Plan of correction due date: May 8, 2024

87412 Personnel Records. (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on staff and administrator's statements, not all staff files were present and available for review and the (3) that were reviewed did not have all of the requirement documentation, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: Licensee/Administrator agree to ensure that each staff has a complete personnel record per Regulation 87412 and all staff records are maintained on site. Signed statement that Reg 87412 has been read and understood. LPA Hood to check staff files during a future visit.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a case management inspection and initially met with with care staff, Kerry Parchmont and Nancy Carr. Edith Spiveyhorn, Lead Staff, arrived at approximately 2:-00 pm. During the course of complaint investigation (59-AS-20240321145120), it was discovered that an incident report was not submitted timely to the Department following a resident's (R1)'s fall at the facility on 3/9/24. An incident report was submitted for the incident on 4/8/24, after the Department requested it be. Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited on the 809-D page. Exit interview with Lead Staff as Administrator was not available during this time. Copy of report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Apr 24, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 8, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) 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 of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on interviews and review of the Department's files, an incident report was not submitted for resident (R1) following a fall on 3/9/24, which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2024

Plan of correction: A completed incident report was submitted on 4/8/24 to the Department. Licensee/Administrator agree to read Regulation 87211 and send a signed statement to the Departent by 5/8/24.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Angela Hood met with the Administrator, Shane Stumpf, to conduct a Pre-licensing visit. There are currently no residents. Administrator has a current certificate #6059131740 with an expiration date of 6/6/2025. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are three (3) bedrooms and two (2) bathrooms for resident use. LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 108.6 degrees F. LPA checked the kitchen area for the ability to prepare and store food. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home to be operational. Fire extinguisher and first aid kit are maintained and ready for emergency use. Pre-licensing passed and LPA waived Component III. Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 8, 2023

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 26, 2023