Jazba Glenroy

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with 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 reviewed R6's LIC 602, dated 8/29/25 and observed that R6 was diagnosed with MRSA (medication resistant staphylococcus aureus). The physician completing the form indicated an end date for the infection of 10/31/25. LPA Moleski reviewed R6's file and observed a documented admission date on 9/3/25. LPA Moleski spoke with R6's responsible party over the phone, who confirmed that they had been informed of R6's diagnosis by medical staff. 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 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 106 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 (S4). Residents were not able to be interviewed. This facility is hereby cited per 22 CCR Section 87615(a)(4). An exit interview was held with Vipulananda. Appeal rights and a copy of this report was left with Vipulananda.the state’s words, verbatim · CDSS document, Sep 29, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a quarterly monitoring visit. LPA Moleski met with administrator Sangeetha Vipulananda and explained the purpose of the visit. LPA Moleski reviewed two resident files (R1-R2) and one staff file (S1). 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 118 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. 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 12, 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 four resident files (R1-R4) and one staff file (S1). LPA Moleski reviewed two incident reports for R4. One incident report, dated 2/11/25, described a staff member providing the resident with their nighttime medications instead of their morning medications. Another report, dated 12/27/24, described R4 suffering an unwitnessed fall. LPA Moleski reviewed CCLD fax and email records and did not observe any indication that these reports had been sent in within seven days of the incidents described. 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 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. While inspecting medication storage areas, LPA Moleski observed two loose medication tablets at the bottom of a bin containing pill bottles and packages. 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. This facility is hereby cited per 22 CCR Sections 87465(a)(4), 87465(h)(5), and 87211(a)(1)(D). 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, Feb 21, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Feb 22, 2025

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on record review and interview, a resident (R4) was given the wrong medications on one occasion, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Licensee agrees to providde LPA Moleski a plan for scheduled staff training regarding medications by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(5) · Plan of correction due date: Feb 28, 2025

"(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers." This requirement was not met as evidenced by: Based on observation, medications were not stored in their originally received container, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Licensee agrees to provide a written plan to prevent future occurrences such as observed during this visit by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Feb 28, 2025

"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 incident which threatens the welfare, safety or health of any resident..." This requirement was not met as evidenced by: Based on record review, CCLD was not notified regarding two unusual incidents, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Feb 21, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a written plan to address reporting requirements in the future by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct an annual inspection. LPA Moleski met with executive assistant Sangeetha Vipulananda and explained the purpose of the visit. This facility currently has zero clients in care. LPA Moleski reviewed two staff files (S1-S2). 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 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 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 working 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 (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, Oct 7, 2024

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

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a quarterly monitoring visit. LPA Moleski met with executive assistant Sangeetha Vipulananda and explained the purpose of the visit. This facility currently has zero clients in care. LPA Moleski reviewed two staff files (S1-S2). 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 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109 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 working 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 (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, Oct 7, 2024

Allegation investigated: Resident eloped from the facility due to lack of care from staff Staff do not provide daily activities for residents Staff did not inform resident's authorized person of incidents of elopement

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). One of the nine staff members interviewed (S8) said that R1 had at one point in time eloped from the facility. S8 said that they had been told by another caregiver, S9, that R1 had escaped through a door in their bedroom and went out into the road. According to S8, staff were told not to inform R1’s RP of the incident. In an interview, S9 said R1 had never eloped from the facility. S6 said that R1 “probably attempted” to elope from the facility, but said staff would have tried to redirect R1. [continued on 9099-C] Unsubstantiated All nine staff members interviewed were able to describe a variety of activities that R1 participated in, such as painting, taking walks with staff, and other art projects. The majority of staff members reported that these activities were sufficient to keep R1 engaged. LPA Moleski observed during multiple previous visits R1 engaged in various kinds of activities, such as coloring and puzzles. The department has determined the following as it relates to the allegations that a resident eloped from the facility due to lack of care from staff, that staff do not provide daily activities for residents, and that staff did not inform a resident’s authorized person of incidents of elopements: 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, Aug 8, 2024 · control 27-AS-20240322120718

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

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 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.the state’s words, verbatim · CDSS document, Aug 8, 2024 · control 27-AS-20240402132940

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 Resident was allowed access to knives

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 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. 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, May 30, 2024 · control 27-AS-20240321120503

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: May 31, 2024

“(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: Based on interviews and record review, a resident was allowed access to knives, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: Licensee has previously removed knives from the drawer and to a separate locked storage area. This POC will be cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(c) · Plan of correction due date: Jun 13, 2024

“(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.” This requirement was not met as evidenced by: 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.the state’s words, verbatim · CDSS document, May 30, 2024

Plan of correction: 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

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, 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 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.the state’s words, verbatim · CDSS document, Mar 25, 2024 · control 27-AS-20240321120503

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Mar 26, 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) or (3) Request and be approved for a transfer of a criminal record exemption..." This requirement was not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Mar 26, 2024

"(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: 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.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: 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

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(5) · Plan of correction due date: Mar 26, 2024

"(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: 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.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Apr 8, 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:" This requirement was not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Licensee agrees to complete all files for re-inspection by POC due date. vincent.moleski@dss.ca.gov

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Shane Stumpf and explained the purpose of the visit. Three staff members (S1-S3) were present in the facility upon arrival (S1-S3). None of these three staff members were associated to this facility's roster. Stumpf submitted transfer documents to the Community Care Licensing Division during this visit. LPA Moleski reviewed six resident files (R1-R6) and seven staff files (S1-S7). LPA Moleski toured the facility with Stumpf 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 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 120 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed 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 (S4) and one resident (R3). This facility is being cited per 22 CCR Section 87355(e)(2). An exit interview was held with Stumpf. Appeal rights and a copy of this report was left with Stumpf.the state’s words, verbatim · CDSS document, Feb 12, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.