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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005410
Report Date: 12/11/2023
Date Signed: 12/12/2023 10:52:13 AM

Document Has Been Signed on 12/12/2023 10:52 AM - 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 HOMEFACILITY NUMBER:
397005410
ADMINISTRATOR:DIZON, JESSICAFACILITY TYPE:
735
ADDRESS:18268 SCHUMARD OAK ROADTELEPHONE:
(209) 323-5590
CITY:LATHROPSTATE: CAZIP CODE:
95330
CAPACITY: 6CENSUS: 5DATE:
12/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Judith Levita and Jessica DizonTIME COMPLETED:
04:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 12/11/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Judith Levita, who was briefly interviewed at this time. It was learned that this caregiver was the sole staff person present at this time while the other staff person was out of the care facility in order to pick up a resident from their day program. There were (4) residents present at this time.
This LPA requested that Mrs. Levita go ahead and contact the facility designated Administrator, Jessica Dizon, to inform her that CCL was present at this time.
The purpose of this visit was to follow up on the items that were requested on an earlier visit dated on 11/15/2023 which have not been received by this LPA. Several attempts were made by this LPA to obtain these forms and documents so now a follow up visit had to be made.

These were the following forms and documents that were originally requested on 11/15/2023:
  • LIC 602

  • LIC 604

  • Any, and all, LIC 624s related to R1 since admission

  • Needs and Appraisal

  • Most recent IPP

  • ID/Emergency Contact
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 12/12/2023 10:52 AM - It Cannot Be Edited


Created By: Charlie Yang On 12/11/2023 at 03:21 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SCHUMARD CARE HOME
FACILITY NUMBER: 397005410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
80064(a)(3)

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The administrator shall have the following qualifications:
Knowledge of and ability to comply with applicable law and regulation.
This facility designated Administrator failed to meet the above cited regulation as evidenced by not corresponding and
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The facility designated Administrator stated that a review of this section that was cited will be conducted. A statement of correction, along with ackowledgement and completion of this section review, will be completed and submitted into CCL by the due date. All requested forms and documents will be
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complying to repeated requests for forms and documents by CCL to aide in an ongoing investigation since 11/15/2023.
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scanned and submitted into CCL as requested since 11/15/2023.

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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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


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
FACILITY NUMBER: 397005410
VISIT DATE: 12/11/2023
NARRATIVE
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The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

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

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC809 (FAS) - (06/04)
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