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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700130
Report Date: 06/17/2024
Date Signed: 06/17/2024 01:13:13 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/17/2024 01:13 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SCHUMARD CARE HOME #2FACILITY NUMBER:
392700130
ADMINISTRATOR/
DIRECTOR:		DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:4680 GLENBROOK DRIVETELEPHONE:
(510) 861-7497
CITY:TRACYSTATE: CAZIP CODE:
95377
CAPACITY: 6CENSUS: 5DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Jessica Dizon TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 06/17/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by Staff Member (SM), Ester Cervantes and explained the purpose of the visit. There were two other staff members present, TJ Castro and Jazmin Virrueta. LPA asked that the staff call the Facility Designated Administrator (FDA), Jessica Dizon to inform her that CCL was present at this time. At 12:00pm, LPA Pascua met with FDA Dizon.

Current census was 5. 3 out 5 residents were out at the respective day programs at this time. A brief interview with FDA Dizon was conducted.
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.

LPA reviewed 5 resident files and 5 staff files. All resident and staff files were current and up to date. The facility designated Administrator does not have a current administrator certificate however the LPA has verified that the administrator has sent in renewal documentation prior to the administrator certificate expiration date on 03/28/2024 and is awaiting renewal from the department at this time.
LPA toured the facility with FDA Dizon. Smoke detectors and carbon monoxide was observed to be in good repair.
The kitchen area was toured. Food supply was reviewed. 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 kitchen cabinet and made inaccessible to the residents at this time. Fire extinguisher located in the kitchen was serviced on 03/04/2024.

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.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SCHUMARD CARE HOME #2
FACILITY NUMBER: 392700130
VISIT DATE: 06/17/2024
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LPA observed a locked centralized stored medication cabinet located in the hallway. Along with staff, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components.

A tour of the garage was conducted. Additional non-perishable food supplies were identified. 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 610e

A technical advisory was provided for 80075(b) and 80088(e)(2).

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

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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