<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700130
Report Date: NO Visit Data Available
Date Signed: 04/03/2024 02:10:29 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231211133320
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:
UNANNOUNCEDTIME BEGAN:
MET WITH:Jazmin VirruetaTIME COMPLETED:
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility Administrator is not at the facility for a sufficient amount of time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/28/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with staff member (SM), Jazmin Virrueta and explained the purpose of the visit. LPA asked SM Virrueta to call the Facility Designated Administrator (FDA), Jessica Dizon to inform them that CCL was present at this time. FDA Dizon was unable to answer the phone at this time. LPA continued the visit with SM Virrueta. The purpose of this visit was to deliver complaint findings for the allegations above.

Current census was 6. A brief interview with SM Virrueta was conducted.

It was alleged that the facility administrator is not at the facility for a sufficient amount of time. During the course of this investigation, this LPA reviewed facility records and conducted interviews. Based on records reviewed, the Facility Designated Administrator is at the facility Monday-Thursday from 10:00am to 8:00pm, and available throughout the day on Saturday and Sunday. An interview with 6 staff members were conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

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

DATE:
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20231211133320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
6 out 6 staff members state that the Facility Designated Administrator does come to the facility, however is there 2 to 3 times throughout the week ranging from 1-2 hours at a time. Based on the information gathered, the facility administrator is not at the facility for a sufficient amount of time.

Based on observations, review of records and information gathered through interviews, the above allegations were SUBSTANIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

An exit interview was conducted, a copy of the LIC9099, LIC9099-C, 9099-D, and appeals rights was provided to the Facility.

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

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20231211133320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2024
Section Cited
CCR
85064(e)
1
2
3
4
5
6
7
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
This is not met as evidenced by:
1
2
3
4
5
6
7
The licensee shall submit a plan to ensure that the administrator is here for a sufficient amount of hours. The licensee shall provide an updated schedule weekly and send to the LPA via email by POC date 04/30/2024.
8
9
10
11
12
13
14
Based on observation and record review, the licensee does not ensure that the administrator is not here for a sufficient amount of time. It as stated through staff interviews that the administrator is here 2-3 times a week, however is only here for a couple hours. This poses an potential health, safety, and personal rights risks to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/11/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20231211133320

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:
03/28/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jazmin VirruetaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff mismanaged resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/28/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct a complaint visit. LPA met with staff member (SM), Jazmin Virrueta and explained the purpose of the visit. LPA asked SM Virrueta to call the Facility Designated Administrator (FDA), Jessica Dizon to inform them that CCL was present at this time. FDA Dizon was unable to answer the phone at this time. LPA continued the visit with SM Virrueta. The purpose of this visit was to deliver complaint findings for the allegations above.
It was alleged that the staff mismanaged the resident’s medication. During the course of this investigation this LPA reviewed facility records and conducted interviews. Based on interviews conducted it was learned that S1 was assisting a resident with their medication. It was stated by their responsible party that the medication did not look correct and it was the wrong medication. S1 went back to the medication cabinet to double check that the correction medication was given. It was stated by the responsible party that S1 confirmed it was the wrong medication however it was denied by staff that the wrong medication was provided and the resident started to reach for another resident’s medication which caused for the confusion.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20231211133320
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/28/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff never confirmed that the resident was going to take the wrong medication therefore there was not a medication error. Based on facility records, this LPA reviewed Medication Administrator records for December 2023 revealed that medication are documented appropriately to indicate when medication was taken or refused. LPA Pascua observed medication stored at the facility to match physician orders and medication dispensing logs. LPA conducted an audit and reviewed medication was dispensed accurately and matched with the count of medication available. Based on observation, record review, and interviews it is unclear if the facility mismanaged the residents medication at this time.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.



There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5