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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700130
Report Date: 04/27/2023
Date Signed: 04/27/2023 11:17:08 AM

Document Has Been Signed on 04/27/2023 11:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:SCHUMARD CARE HOME #2FACILITY NUMBER:
392700130
ADMINISTRATOR:DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:4680 GLENBROOK DRIVETELEPHONE:
(510) 861-7497
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY: 6CENSUS: 6DATE:
04/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Toribio CastroTIME COMPLETED:
11:30 AM
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On 04/27/2023 at 9:20am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to the facility to conduct an Annual Visit. LPA Pascua was greeted by staff member, Jazmin Virrueta and explained the purpose of the visit. It was asked by the LPA to call the Facility Designated Administrator to inform them that CCL was present at the facility at this time. It was learned at this time that the Facility Designated Administrator was unable to come to the facility at this time. LPA was directed that she may continue her visit with Facility Designated Representative (FDR), Toribio (TJ) Castro.
Current census is 6. 1 out of 6 residents were out at their respective day program at this time. This facility is licensed to serve up to 6 ambulatory residents. This facility is also vendorized by Valley Mountain Regional Center to accept and serve 4I residents at this time.
At 9:30am, LPA reviewed 6 resident files. 6 out of 6 resident files were complete and up to date. LPA reviewed 4 staff files. 4 out of 4 staff files were complete and up to date. The Facility Designated Administrator, Jessica Dizon has an active administrator certificate #6029775735 and expires on 03/30/2024.
At 10:30am, LPA initiated a tour with FDR Castro.
LPA observed a locked centralized stored medication cabinet located in the hallway. Along with FDR Castro, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.
The interior of the physical plant was in good condition and sanitary. Fire extinguisher located in the kitchen was observed to be in compliance and in good repair. Carbon monoxide and smoke detectors were observed to be in good repair.

The kitchen area was toured. LPA observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional perishable and non-perishable food supplies were identified in the garage. Knives were observed to be locked in a hallway and made inaccessible to the residents at this time.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: SCHUMARD CARE HOME #2
FACILITY NUMBER: 392700130
VISIT DATE: 04/27/2023
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A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time.

A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time.

Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional non-perishable food supplies were identified. Additional storage for supplies and files were stored in cabinets. All cleaning supplies were locked and made inaccessible to residents at this time.

The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

No deficiencies were observed or cited during this annual visit.

Exit interview was conducted and a copy of this report was provided to the facility at the end of the visit.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023
LIC809 (FAS) - (06/04)
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