Jazba Care Tuolumne

Allegation investigated: Resident sustained a fracture while in care due to staff neglect Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with senior house manager Brittany McCoy and explained the purpose of the visit. The Community Care Licensing Division (CCLD) received an incident report on 7/11/25 regarding a resident’s (R1’s) unwitnessed fall. According to the report, R1 fell on 7/9/25 around 6:20 a.m., but was not complaining of pain, and did not present any apparent injuries upon inspection. R1 was sent to the emergency room on 7/10/25 around 4:45 p.m. after they began to complain of pain to a family member, according the report. Medical records obtained by CCLD indicated that R1 was diagnosed with a fracture of their pubic bone. [continued on 9099-C] Unsubstantiated In an interview, R1’s responsible party (R1’s RP) said that facility administrator Sangeetha Vipulananda called them after R1 fell on 7/9/25, and was told that R1 was fine and not complaining of pain. R1’s RP said they spoke with R1 over the phone the next day, 7/10/25, and R1 began complaining of pain. R1’s RP requested staff to have R1 sent to the hospital on 7/10/25. In an interview, a staff member on duty at the time of R1’s fall (S1) said that they observed another resident (R2) enter into R1’s room on the morning of 7/9/25. When S1 redirected R2 from R1’s room, S1 observed R1 on the floor near their bed. According to S1, R1 said that they became scared when R2 entered their room, and fell out of bed as a result. S1 said they assisted R1 up and conducted a body check, but observed no obvious signs of injury. S1 provided CCLD with a photograph taken of R1’s back, which appeared grossly unremarkable. According to S1, R1 did not complain of pain throughout 7/9/25 and 7/10/25. A second staff member on duty at the time did not appear for a scheduled interview with CCLD. In an interview, R1 was able to recall their fall. “I was asleep and rolled out of bed,” R1 said. R1 did not remember being in pain after their fall. Medical records obtained by CCLD indicate that R1 told first responders who arrived at the facility on 7/10/25 that they did not initially experience pain after their fall, but they were experiencing pain when trying to move their leg on 7/10/25. R2 was not able to recall R1’s fall and did not have pertinent information to share with CCLD. The department has determined the following as it relates to the allegations that a resident sustained a fracture while in care due to staff neglect, and that staff did not seek medical attention for a resident in a timely manner: Based on interviews 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 McCoy.the state’s words, verbatim · CDSS document, Nov 13, 2025 · control 27-AS-20250714090127

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). LPA Moleski toured the facility with Vipulananda 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 76 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, 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 (S1) and one resident (R4). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, Sep 11, 2025

Allegation investigated: Licensee is operating beyond the scope of license

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Sangeetha Vipulananda and explained the purpose of the visit. This investigation consisted of observation, interviews, and record review. LPA Moleski reviewed a resident's file (R1). LPA Moleski observed that they had an admission agreement for another facility, but not this facility. LPA Moleski reviewed an incident reporting an unwitnessed fall suffered by R1. According to the incident report, R1 was admitted to this facility on 7/5/25 and was sent to the hospital on 7/10/25. Vipulananda said that R1 did not return to this facility after hospitalization. LPA Moleski reviewed the files of six current residents (R2-R7). [continued on 9099-C] Substantiated Four of these residents had signed admission agreements from this facility. R2 was admitted on 5/14/25, R3 was admitted on 10/8/24, R4 was admitted on 2/3/24, and R5 was admitted on 12/28/23, according to their respective admission agreements. Two current residents (R6-R7) who moved in recently had admission agreements from their prior placements, which are also owned and operated by the licensee of this facility. LPA Moleski reviewed medication administration records for R6 and R7. LPA Moleski observed signatures present for both of these residents from a certain staff member (S1) as early as 7/7/25. Vipulananda confirmed that S1 does not work at any other facilities owned or operated by the licensee of this facility. This indicates both R6 and R7 were moved in to this facility as of 7/7/25 at the latest. LPA Moleski interviewed two staff members who were working at this facility over the past two weeks (S1-S2). Both S1 and S2 confirmed that R1-R7 were living at the facility at the same time. Both S1 and S2 said that R1 was living in a staff room on a spare bed, along with the live-in staff member. This facility's license permits the licensee to provide care for no more than six residents at any given time. The department has determined the following as it relates to the allegation that the licensee is operating beyond the scope of license: Based on interviews and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87204(a). An exit interview was held with Vipulananda. Appeal rights and a copy of this report were left with Vipulananda.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 27-AS-20250714090127

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Jul 16, 2025

"(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time..." This requirement was not met as evidenced by: Based on interviews and record review, seven clients were residing in this facility concurrently, despite the fact that this facility's license is for six residents only, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a written acknowledgment of the limitations of this facility's license by POC due date. vincent.moleski@dss.ca.gov

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a quarterly monitoring visit. LPA Moleski met with facility administrator Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed three resident files (R1-R3) and three staff files (S1-S3). LPA Moleski toured the facility with Vipulananda 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 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. 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 during this visit (S2). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, May 22, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a quarterly monitoring visit. LPA Moleski met with facility administrator Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed five resident files (R1-R5) and three staff files (S1-S3). LPA Moleski toured the facility with Vipulananda 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 71 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, fully-charged and up-to-date fire extinguishers, 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 two staff members (S1-S2) and one resident (R4). No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, Feb 20, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a quarterly non-compliance inspection. LPA Moleski met with executive assistant Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). LPA Moleski toured the facility with Vipulananda 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 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, 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 two staff members (S1-S2). No residents were able to be interviewed. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, Oct 14, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct an annual inspection. LPA Moleski met with executive assistant Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S1-S3). LPA Moleski toured the facility with Vipulananda 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 75 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 105 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, 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 two staff members (S1-S2). No residents were able to be interviewed. No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, Oct 14, 2024

Type of visit: Case Management - Legal/Non-compliance

A non-compliance conference was held today, June 28, 2024, in order to discuss substantiated complaints and other serious deficiencies identified by the department. Licensing Program Analyst (LPA) Vincent Moleski, Licensing Program Manager (LPM) Stephen Richardson, Regional Manager (RM) Stephenie Doub, licensee/administrator Shane Stumpf, and Stumpf's executive assistant Sangeetha Vipulananda were in attendance. RM Doub discussed operational and administrative concerns which have been reflected in substantiated complaints, such as acquiring criminal record clearances for new employees and completing the required amount of staff training during onboarding. Stumpf said that she has hired Vipulananda to assist with administrative tasks, and has worked to create checklists and task sheets to streamline these tasks. Stumpf she had not been able to provide sufficient oversight over her facilities, resulting in deficiencies. RM Doub recommended that Stumpf appoint administrators to her facilities in order to delegate administrative tasks while still maintaining oversight over operations. Stumpf agreed, and identified several individuals who may be able to act as administrators. RM Doub offered Technical Support Program referral, to which Stumpf agreed. RM Doub requested that Stumpf provide an updated LIC 500 for her facilities reflecting real hours worked by Stumpf and others, and to appoint administrators to delegate administrative tasks to. Stumpf agreed to provide CCLD a written plan identifying those individuals who are able to be appointed as facility administrators immediately, if any. For those staff members who are still completing their administrator certificates, Stumpf agreed to appoint them as designees and to create job duties for an "assistant administrator" position. [continued on 809-C] The Licensee shall identify these assistant administrators by name and facility, and shall include a written job description with a full listing of their role and responsibilities. Stumpf agreed to provide this plan, LIC 308s for all designees identified, and updated LIC 500s for her facilities by July 8. Stumpf shall also submit the following for any individuals already holding an administrator certificate who are to be appointed facility administrator of record: An LIC 200 indicating change of administrator, an LIC 308, the individual's complete personnel file, proof of education, and a copy of their administrator certificate. RM Doub advised that this facility will be receiving increased monitoring in the form of quarterly visits. No deficiencies were cited during this meeting. An exit interview was held with Stumpf, and a copy of this report was sent to her to sign.the state’s words, verbatim · CDSS document, Jun 28, 2024

Allegation investigated: Staff are not sufficiently trained

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 this visit. This investigation consisted of record review. LPA Moleski reviewed personnel records for six staff members (S1-S6). LPA Moleski observed that all six of these staff members had training records documenting 20 hours of initial training. However, none of these six staff members had documentation of completing the required 40 hours of initial training within their first four weeks of employment, per HSC Section 1569.625(b)(1). 22 CCR Section 87412(c) states that “Licensees shall maintain in the personnel records verification of required staff training and orientation.” [continued on 9099-C] Substantiated The department has determined the following as it relates to the allegation that staff are not sufficiently trained: Based on record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.625(b)(1). An exit interview was held with Stumpf. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf. 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.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 27-AS-20240321114138

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Jun 26, 2024

“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. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.” This requirement was not met as evidenced by: Based on record review, staff members did not receive the required 40 hours of initial training within their first four weeks of employment, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee agrees to provide LPA Moleski a 40-hour training sign-in sheet by POC due date. vincent.moleski@dss.ca.gov

Allegation investigated: Staff does not ensure disaster drills are being conducted

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. According to Stumpf, emergency disaster drills have been conducted during staff meetings, which were not mandatory for all staff to attend. The drills were not conducted during each consecutive shift, but staff members of all shifts were invited to attend. LPA Moleski reviewed staff meeting agendas from February 2022 to present. For the year of 2022, LPA Moleski observed four staff meeting agendas from February, May, July, and November. [continued on 9099-C] Substantiated The agendas indicate emergency disaster topics such as storms, blackouts, and fire safety were discussed at each. A list of attendees is provided at each. Staff schedules and employee sign-in sheets from various dates were provided by Stumpf to verify attendance. The February meeting shows four staff members attended out of six staff members employed in the same month, per employee sign-in sheets. The May meeting shows five staff members attended out of seven staff members employed in the same month, per staff schedules. The July meeting shows five staff members attended out of six staff members employed in the same month, per staff schedules. The November meeting shows five staff members attended out of seven staff members employed in the same month, per staff schedules. For the year of 2023, LPA Moleski was provided staff meeting agendas from January, February, April, July, and October. The January meeting agenda indicates blackout and power outages were discussed, however, there is no list of staff in attendance. The meeting agendas for February, April, and October indicated emergency disaster topics were discussed and provided lists of attendees. The meeting agenda for October does not indicate any emergency disaster topics were discussed. For the year of 2024, LPA Moleski observed two staff meeting agendas. The first, from January 2024, did not contain a list of staff in attendance, and did not indicate that any emergency disaster topics were discussed. The second agenda, from April, contained a list of staff in attendance and indicated that a fire training was held. The department has determined the following as it relates to the allegation that staff do not ensure disaster drills are being conducted: Based on record review, 2022 emergency disaster drills were conducted, but not for all staff members of each shift as required, and, for the years of 2023 and 2024, drills were not conducted every quarter as required. Therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.695(c). An exit interview was held with Stumpf. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf. The department has determined the following as it relates to the allegation that the facility does not have a sufficient amount of food for residents: Based on observations, interviews, and record review, the above allegation is UNSUBSTANTIATED, which means 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. No deficiencies were cited regarding the above allegation. An exit interview was held and a copy of this report was left with Stumpf.the state’s words, verbatim · CDSS document, Jun 12, 2024 · control 27-AS-20240419113158

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(c) · Plan of correction due date: Jun 26, 2024

“A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.” This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the above section, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee agrees to provide a staff meeting template containing spaces to complete required emergency disaster information for each quarter and agrees to send LPA Moleski a copy by the POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a complaint visit. During the visit, LPA Moleski observed deficiencies as described below. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit. When LPA Moleski arrived, two staff members were present (S1-S2). LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility roster. In an interview, S1 said that S1 started working at this facility in early March. S1 said S1 did not have regular shifts, and had worked at this facility for an estimated total of 10 to 20 days. This facility is being cited per 22 CCR Section 87355(e)(2). This facility was previously cited under this same section on 3/29/24. An immediate civil penalty in the amount of $1,000 was assessed for a repeat violation. Civil penalties in the amount of $100 per day for 15 days for a total of $1,500 were also assessed. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf.the state’s words, verbatim · CDSS document, May 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 2, 2024

"(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 was not met as evidenced by: Based on observation, interview, and record review, S1 was working in this facility for a period of TKTK days without having an appropriate clearance transferred, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, May 1, 2024

Plan of correction: Licensee agrees to associate S1 through Guardian by POC due date. Licensee shall notify LPA Moleski after having done so. vincent.moleski@dss.ca.gov

Allegation investigated: Staff members worked at facility without criminal record association Staff files are incomplete

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 at the facility, one staff member was present (S1). In an interview, S1 said that S1 had been working at the facility since November or December 2023. LPA Moleski reviewed Guardian records and observed that S1 was associated to the facility as of 3/26/24, one day after LPA Moleski opened a separate complaint investigation regarding criminal record clearances at another facility owned and/or operated by Stumpf. S1 said S1 had been working six days a week at the facility since starting. S1 said S1 had been working with S2 for about a month. [continued on 9099-C] Substantiated S2 arrived during this visit. In an interview, S2 said S2 had been working at this facility since about mid-February. S2 said S1 had been working at this facility since before S2 started working here. LPA Moleski reviewed Guardian records and observed that S2 had been associated to this facility as of 3/27/24. Stumpf said S1 started working at this facility around the end of last year. Stumpf said that S2 had been working at the facility for less than a month. In an interview, a consultant who had been working for the licensee (S7) said multiple staff members worked at this facility without having appropriate criminal record associations. LPA Moleski reviewed S2's file. S2 did not have a health screening on file, despite having worked more than seven days at this facility. The department has determined the following as it relates to the allegations that staff members worked at this 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 hereby cited per 22 CCR Section 87355(e)(2) and 87412(a)(11). A civil penalty in the amount of $100 per day for a total of ten days was assessed. As this is the first violation of criminal record requirements documented at this facility, a total of five days for each day worked for each staff member is the maximum amount to be assessed. An exit interview was held with Stumpf. Appeal rights and a copy of this report were left with Stumpf.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 27-AS-20240321114138

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 30, 2024

"(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) ..." This requirement was not met as evidenced by: Based on interviews and record review, S1 was working for several months without having a criminal record association at this facility, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Licensee agrees to read and review the requirements pertaining to criminal record clearances, and to write a statement acknowledging that criminal record transfers must be completed prior to starting work. Licensee shall provide this to LPA Moleski by the POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(11) · Plan of correction due date: Apr 5, 2024

"(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 ... (11) A health screening as specified in Section 87411, Personnel Requirements - General." This requirement was not met as evidenced by: Based on record review, S2 did not have a health screening on file, despite having worked more than seven days, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Licensee agrees to provide LPA Moleski S2's health screening by the POC due date. vincent.moleski@dss.ca.gov

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.