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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700130
Report Date: 12/03/2024
Date Signed: 12/03/2024 02:11:56 PM

Document Has Been Signed on 12/03/2024 02:11 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: 6DATE:
12/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jessica Dizon TIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 12/03/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a case management visit. LPA met with Facility Designated Administrator (FDA), Jessica Dizon and explained the purpose of this visit.
The purpose of this visit was to follow up on an incident report that was sent into the department on 12/02/2024.
Current census was 6. 3 out 6 residents were out at appointments or at their respective day programs at this time.
A brief interview with FDA Dizon was conducted.

On 12/02/2024, the department received an incident report from this facility that stated that the facility took some residents out to an outing where R1 became upset with R2 because they were playing their music out loud and did not enjoy their music choice. R1 started to lash out by stating that they wanted to go home and wanted to take a walk. During this time S1 and S2 were in the car attempting to de-escalate R1 while driving on the highway. S1 and S2 explained to R1 that it was not safe for them to take a walk due to the fact that they were driving on the freeway. In response, R1 decided to hit S1 and bite S2 on the arm. R2 observed R1 hit staff and stated not to do so. R1 then decided to hit R2 while they were in the back-seat. In response, S1 pulled the car over and took measures such as performing first aid to ensure that both residents were not in need of medical attention and were able to de-escalate the situation.

The facility notified licensing, the regional center and the residents responsible parties. The facility has also stated that they are currently working with R1's service coordinator and the behaviorist to ensure that there is a proper plan in place to help mitigate or de-escalate R1's behaviors.

Based upon interviews and documentation reviewed and received, no violations or deficiencies have been issued during today's visit. An exit interview was conducted and a copy of the LIC809 was provided upon exit.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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