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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005410
Report Date: 07/13/2023
Date Signed: 07/14/2023 03:51:38 PM

Document Has Been Signed on 07/14/2023 03:51 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
07/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Toribio (TJ) CastroTIME COMPLETED:
01:00 PM
NARRATIVE
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On 07/13/2023 at 10:00am Licensing Program Analyst (LPA) Arielle Pascua and Valley Mountain Regional Center Liaison (VMRCL), Jennifer Stone arrived to this facility unannounced to conduct a case management visit. LPA Pascua and VMRCL Stone were greeted staff member (SM), Maria Aquino and explained the purpose of the visit. LPA asked that SM Aquino contact the Facility Designated Administrator, Jessica Dizon to inform her that CCL and VMRC were present at this time. It was learned that the FDA was unable to come to the facility but was going to ask the Facility Designated Representative, TJ Castro to come to the facility. At 10:30am, FDR Castro arrived at the facility.
Current census was 6. 5 out of 6 residents were out at their respective day programs.
A tour of the facility was conducted. A brief interview with FDR Castro was conducted.
The purpose of this visit was to follow up on an incident that was received by the department on 07/07/2023 concerning R1. It was learned that around 3:30pm, several individuals rang the doorbell and demanded for R1 because they stole marijuana from them. Staff asked the the individuals calm down so that they could understand what happened. The individuals propped a gun at the staff members face and demanded for the resident. The individuals tried to gain entrance the facility but was unable to obtain entrance. The staff gathered all the residents in a secluded area while they called 911. The individuals began to walk around the facility banging and destroying different parts of the house. As the staff waited for the police, the individuals were able to obtain entrance through the back sliding glass door. The individuals questioned R1 in the front living room and ran out. The police arrived shortly after and were able to apprehend the individuals and mitigate the situation.
LPA Pascua conducted staff interviews. LPA reviewed facility records including but not limited to, emergency plan, R1's IPP, Admissions Agreement, Medication Administration Record, and Psychiatric Evaluation. It was learned based on interviews conducted the the facility chose to turn off the internet as a form of intervention to mitigate any further incidents.
Based upon interviews and documentation reviewed and received, The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations. Exit interview conducted with TJ Castro, a copy of the LIC809, LIC809-D and appeals rights were provided upon exit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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Document Has Been Signed on 07/14/2023 03:51 PM - It Cannot Be Edited


Created By: Arielle Pascua On 07/13/2023 at 11:29 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: SCHUMARD CARE HOME
FACILITY NUMBER: 397005410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2023
Section Cited
CCR
80072(a)(3)

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80072(a)(3) Personal Rights
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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The Facility shall provide a plan in place to help mitigate the resident's behavior. The facility shall provide a statement of correction of understanding of the following citation 80072(a)(3). The statement of correction and a copy of the plan shall be sent to the LPAs email by the POC date.
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This is not met as evidenced by: Based on interview and record review. The facility did not ensure that the R1 was free of punishment. The facility shut off the resident's internet access by changing the password. A review of the resident's file did not show that the facility has a proper plan in place with the Regional Center to ensure that this intervention was to help the resident's wellbeing. This poses an immediate health, safety, and personal rights risk to the persons in care.
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Arielle Pascua
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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