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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005410
Report Date: 12/19/2024
Date Signed: 12/24/2024 09:15:25 AM

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
12/11/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241211110127
FACILITY NAME:SCHUMARD CARE HOMEFACILITY NUMBER:
397005410
ADMINISTRATOR:DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:18268 SCHUMARD OAK ROADTELEPHONE:
(209) 323-5590
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY:6CENSUS: 6DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica DizonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff mishandled a client's medication while in care
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 12/19/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Jessica Dizon. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 6 residents, of which, 3 of them were out of the facility at their respective day programs at this time.
This facility is also vendorized through Valley Mountain Regional Center, VMRC, to be able to accept and retain Level 4I residents at any given time.
It was learned that this facility, through VMRC, was expected to maintain a ration of 3:1 in terms of facility residents to facility staff being present at all times.
The purpose of this visit was to inform this facility, and its representatives, that a complaint had been filed along with the above allegation.
Based on interviews conducted during the course of this investigation, it was learned that R1 was deemed to be able to dispense their own prescribed and PRN medications. It was learned that R1 was also able to
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 3
Control Number 27-AS-20241211110127
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
FACILITY NUMBER: 397005410
VISIT DATE: 12/19/2024
NARRATIVE
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handle all of R1's own medical and dental appointments with assistance from the facility staff if requested by R1.
Based on a review of the facility Medication Administration Record (MAR), it was observed that from the months of February 2024 until November 2024, there weren't any entries, with initials, in regards to the resident R1 taking, refusing, or missing R1's medications for this duration of time. It was observed that there weren't any supporting notes or comments entered into the MAR for this resident at all. It was learned that this LPA was left to assume that the prescribed medications were not properly dispensed, handled, and documented during this span of time for the resident R1 since there wasn't any documented proof of facility staff dispensing the medications to R1..
Based on a review of the facility forms and documents, it was learned that R1 was deemed to be unable to manage and store R1's own medications per the LIC 602 that was completed and signed off by R1's attending licensed medical professional at that time.
Based on a review of the facility forms and documents, it was learned that R1 was deemed to be able to handle R1's own medical needs with setting appointments, going to and from appointments, and follow up as needed. It was learned that R1 was still unable to be able to manage R1's own medications and required that this facility had to properly handle, dispense, and document them at this time.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20241211110127
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
FACILITY NUMBER: 397005410
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2024
Section Cited
CCR
80078(a)
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The licensee shall provide care and supervision as necessary to meet the client's needs.
This facility was found to be deficient as evidenced by the lack of oversight, communication, and proper documentation of the resident's medications which should
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The facility designated Administrator stated that all facility Medication Administration Records (MARs) will be reviewed and updated to reflect the correct medication, dosage, and time when the meds are dispensed for all facility resident records. All facility staff able to handle, dispense, and
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have been taken on a routine and PRN basis as prescribed by the licensed medical professional. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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handle the resident medications will be trained by a third party vendor for no less than (1) hour in duration on the subject matter of proper handling, dispensing, and documentation of the facility resident medications. A statement of correction, along with proof of completed training, will be completed and submitted into CCL by the due date.
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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: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3